Dianostic Error

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The clinic dutifully followed the instructions for "E" codes, workman compensation codes. It was a simple fracture of a finger. When the response, with payment, came back, the diagnosis listed was gonorrhea resulting from a fall from aircraft.

Who is to say how this error occurred. Was it the insurance clerk exercising humor, a mistaken entry, a change in code numbers by the commission or an error in theirs or our computer.

Unfortunately, the above is not the only source of spurious diagnosis. In many cases the insurance clerk faced with, looking up the proper ICDA code from the clinician's notes, picks the one that justifies the laboratory and treatment ordered. She does so in  order to receive remuneration -- her responsibility. Even when the clinician lists the appropriate ICDA, the clerk may likely change it in order to met the criteria for payment. This manipulation of diagnostic code might be considered fraud. On the other hand, the clinic provided an honest service, rendered a diagnosis that may not exactly fit the codes and criteria. The clerk is fulfilling her duty to the clinic, the coding system and the patient. The clinic is therefore resolving ambiguities in good faith. However, the coded diagnosis may not accurately reflect the diagnosis for the patient.

Moreover, many clinicians are reluctant to record any diagnosis that the insurance company can call a preexisting condition. A noble concern, but one that erodes the acknowledgement of  early risk or the identification of incipient disease.

When one adds to these sources of erroneous diagnosis and the all to frequent missed or wrong diagnosis, there results a database of demographics and diagnosis that is corrupt from the start. A system of confirmed diagnosis might help.

Will the ACA or the EHR eliminate these sources of error? Probably not, the patient confidentiality issue remains. Even though the insurance company may no longer be able to deny preexisting conditions, the patient information is none the less in their database. The draconian rules limiting access to patient data makes it difficult for clinicians to coordinate care or the patient to access his or her information; whereas the system makes the information readily available to insurance companies and government. If Equifax wants to know if you have HIV, they are going to find out.

Lastly, how do you know that the diagnosis is correct even at best. Autopsy results find as much as 60% missed or wrong diagnosis. That is not to say that missed or wrong diagnosis occurs 60% of the time, but among patients who die, the missed or wrong diagnosis may be critical information. Shamefully, autopsy is a thing of the past. Blame it on families, fears of litigation, cost or hospital inconvenience, a revenue issue.  Autopsy is the final analysis, but who will pay for it?

Undiagnosed Hypertension

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|With 36 million estimated cases of uncontrolled hypertension, 14 million of whom are unaware and undiagnosed, there exists a target rich environment for the life saving diagnosis of hypertension.

Why should this be when most of these people visit clinics and doctor's offices, but remain unaware? A small number suffer the rather high threshold some doctors set for the diagnostic criteria for hypertension. The majority, however, represent a negligence in both the taking of blood pressures and the recording of the results stemming largely from cost cutting and sheer boredom.

Very few assistants know how to take a blood pressure. Rather than teaching them the right way and training them to a level of competency, accuracy and consistency, they are turned loose either with superficial knowledge or with an automated blood pressure cuff and recording instrument that may or may not be accurate and is still dependent on the assistant's ability to use the instrument correctly. If a clinician wants to treat more patients that are appreciative and save lives, the clinician would be well advised to take blood pressures his or herself.

Mechanized BP apparatuses notoriously give spurious results even the most expensive in the wrong hands. Moreover, what good is an automated cuff in the hands of a physician; he or she might rather use a mercury manometer and be certain. Today's hurried schedules with highly discounted reimbursements lead to a focus on a single problem. Ancillary abnormal findings get overlooked or discounted as probably in error. Sad but true, this happens and what more relevant condition can there be than the early diagnosis of hypertension along with the appropriate workup for underlying causes.

A proper BP reading requires an appropriate size cuff, a mercury manometer, and a stethoscope. The cuff should go first to the right arm in order not to miss Coarctation of the Aorta. The patient must fully extended the arm and raise it to chest level. The assistant must palpate a strong pulse placing the bowel of the stethoscope over the pulse while pumping the pressure to a safe level above the audible pulse, approximately 200 mm. Open the valve only a little so that the pressure drops slowly. Record the pressure for the first audible pulse, a rather distinct and abrupt point, easy to determine. Continue listening as the pressure falls. Record the first abrupt weakening change in sound and continue listening until no sound is heard recording that number as well. In some patients, there will be only one clear disappearance of sound while in others there are two changes to consider for the diastolic pressure, record them both. With only borderline BP, take another reading and do so for both arms. Record all readings such as 120/80-70 RA sitting. Include the position of the patient as well as the arm or leg. Always take multiple readings if pressure is above 120/70 and if above 140/90 take BP in one of the legs using a large cuff. Relegate BPs to only well known and trusted nurses and check even that during your physical exam. Take the patient’s pulse yourself as well; both make interesting conversation during your exam and lead to relevant system review questions.

The JAMA article below speaks of treatment protocols, but the diagnosis and workup come first. A treatment protocol may unerringly select the right treatment for the statistically average American patient but miss completely the appropriate treatment for the patient sitting before you. Many other conditions influence the choice of medications for treatment.

http://jama.jamanetwork.com/article.aspx?articleID=1778410&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst11%2F14%2F2013