Misdiagnoses and diagnostic imaging: 2 hospital CEOs on subspecialty radiology's role

Most Americans will experience a diagnostic error at least once in their lifetime, according to the Institute of Medicine's September report "Improving Diagnosis in Healthcare."

While misdiagnoses can occur at any point in the diagnostic process, many misdiagnoses are tied to diagnostic imaging. The level of clinically significant or major error in radiology ranges from 2 to 20 percent, depending on the radiological investigation, according to a 2001 study in the Journal of Radiology.

However, when hospitals and other provider organizations use subspecialty radiologists when the case calls for it, error rates can decline.

Here, Bill Lawrence, president and CEO of McLaren Central Michigan in Mt. Pleasant (part of McLaren Health Care), and Allen Weiss, MD, a physician board certified in internal medicine, rheumatology and geriatrics who serves as president and CEO of NCH Healthcare System in Naples, Fla., discuss the problem of misdiagnosis in healthcare and how subspecialty radiologists play a large role in the solution.

This content is sponsored by Sheridan Healthcare

Question: The IOM recently released a report on improving diagnosis in healthcare. How big of an issue is misdiagnoses?

Bill Lawrence: Specifically with diagnostic imaging, the issue can be very significant. Some of the data suggest there may be an excess of 20 percent error rate and that is certainly problematic.

Dr. Allan Weiss: It's an issue. The problem is that we never typically know it's a misdiagnosis. The patient may or may not suffer, and certainly the people involved are embarrassed and not anxious to share that, so we never really know what our quality is.

There's an old Shakespearean saying that the cemetery is full of doctors' mistakes. It's not a pleasant quote. But we really haven't been as objective as we could be in the age of digital medicine and digital communication. Having something like radiology, where there's an image or series of images that can be reviewed separately and independently — the differences that you come out with are astounding.

There was a study out of Massachusetts General Hospital, where they showed the same radiologist the same images six months apart. A significant amount of time, they would come back with a different diagnosis. Even when you have two radiologists reviewing the same image, the discrepancies are significant.

Q: What role does radiology play in misdiagnoses in healthcare and beyond?

BL: I think it plays a very significant role. Certainly, diagnostic imaging is one of the principle areas that physicians use to diagnose illness and determine treatment. So I think diagnostic imaging plays an incredibly important and significant role.

AW: There are five ways to make a diagnosis: history, physical exam, testing (like radiology, blood tests, EMGs, etc.), treat to see if they get better, and wait and see if the diagnosis gets better. Unfortunately, radiology is an area ripe for misdiagnoses.

Q: How important is subspecialty radiology to you and your organization, and why is it important?

BL: I believe subspecialty radiology is important because it allows us to access physicians who have specialized training in given areas, and I believe these radiologists are capable of providing higher quality results by specialty than the general radiology community. The two most visible subspecialists are in the areas of neuroradiology and mammography. It's not that there aren't other subspecialty radiologists, but those two are typically used as examples of how subspecialty radiology might be superior to general radiology.

AW: If you ask a pediatric radiologist to read an adult exam versus reading a pediatric exam, I think the results will be significantly different. Someone who is an expert in jewelry to look at some other type of craft, they don't know the business as well. You need to have a certain comfort level.

Subspecialty radiology is very important. We treat a lot of patients in neurological radiology and pediatrics, which require more of a specialty.

Q: What would the ideal radiology service look like for your organization?

BL: It would be a combination of subspecialty radiologists reading the studies that are associated with their subspecialties and the availability of highly skilled interventional radiologists on-site to meet the demand imposed by the need for interventional radiologist procedures.

AW: It would have a high level of accuracy, rapid response, excellent communication among the clinicians and an expertise to help us do better in the long term.

Q: What advice would you give to other hospital executives when it comes to building a radiology service?

BL: Well, I think what we're looking for as hospital CEOs — in terms of diagnostic imaging — is a balance that will provide us with the subspecialty resources that we need to achieve high levels of quality, as well as the availability of local interventional resources to meet the 24/7 demand associated with that unique need.

The thing that really sticks in my mind about my experience with subspecialty radiology is that Sheridan is the first imaging provider to generate ongoing quality data associated with the correct interpretation of findings. Throughout my career I've dealt with any number of radiology providers, but this is the first time a provider has come to me with an evaluation of the quality of the work they are producing.

I get reports quarterly about the level of errors they're encountering with the interpretations that they do. In the beginning, they had error rates that were already low, and over a period of five years, they've driven error rates down to 1 percent. I've been very impressed.

AW: I would carefully look at their quality assurance program — that includes the number of overall reads, consistency and the time it takes to get a report done. We want quick results, since we have pressure around length of stay, and accuracy for the patients' well-being.

In the future, we are going to do more and more subspecialty radiology with telecommunications. The Internet is the perfect use of that tool.

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