NQF President Dr. Christine Cassel: Diagnostic Improvement Means Embracing Imperfect Progress

Improving diagnosis accuracy has long been dismissed as something too difficult to tackle. However, diagnosis improvement is a crucial part of raising the bar for healthcare quality and professionalism in the United States, according to Christine Cassel, MD, president and CEO of the National Quality Forum. Dr. Cassel shared insights on improving diagnostic accuracy as a keynote speaker at the 6th International Conference: Diagnostic Error in Medicine on Monday.


"Everyone who works with patients knows the prevalence of this kind of problem," she said. "There is important work to be done in the field of measurement and important work to be done in advocacy without waiting for the perfect study on diagnostic error to be done. It's not perfect, but that's how policy moves forward."

Dr. Cassel lauded the progress healthcare has made so far in moving quality improvement forward since the creation of the National Quality Forum in 1999. "The availability of quality measures and proliferation of data sources, advances and relationship between quality and payment are so far ahead of where the NQF imagined healthcare would be a decade ago. It's important to think even three to five years from now the amazing changes we can expect in the field," she said.

Physicians as "knaves"
The progress in quality improvement stems in part from a shift in mindset from framing initiatives in terms of problems to framing them in terms of solutions. Before the creation of the National Quality Forum and before the national focus on healthcare quality, Dr. Cassel said there was a consistent theme: Physicians were thought to be the barriers to quality. Quality initiatives worked to incentivize physicians in a way that might improve healthcare quality, while organized medicine wasn't even part of the quality discussion. The solution to influencing physician actions, at first, was public reporting.

When publicly reporting measures became required, the idea was first that patients could use data to choose better-performing physicians and providers. But as it happened, the public reporting initiative didn't lead to much information that patients actually used. The measures were more useful in the context of population health. The measures didn't require physicians to succeed, and what's more, they lacked context for problem solving or diagnostic accuracy.

This conundrum led to Dr. Cassel's 2010 paper, written with Sachin Jain, MD, "Societal Perceptions of Physicians: Knights, Knaves, and Pawns," a work based on ideas from British social policy theorist Julian McRand. The article detailed the fallout action from systems of incentives for physician management. The basic premise is that assumptions of human nature influence resulting policy recommendations. Assume people are good, and incentivizing systems will be enabling policies. Assume people are bad, and systems of incentives are necessarily punitive. The fear was that physicians were being treated like bad people — knaves — and would end up with the mentality of pawns: people who simply respond to directives without any measure of critical thought.

Dr. Cassel stressed that treating physicians as knaves would be an unqualified disaster: Critical thinking and innovation are vital in physicians' line of work, even with the recent proliferation of tools like electronic decision aids. "The trouble is physician work is not an assembly line. Someone without a medical education can't make tools like decision aids work; there must also be a framing, a deep understanding of what's happening," she said, noting that any knowledge base may benefit from continuous revision.

Powerful consumers
Neither enabling nor punitive measurements seem to be the answer to the diagnosis improvement conundrum, although from the perspective of quality measure developers, physician excellence in diagnosis is only possible through accountability. An as-of-yet untapped source for this accountability may be the group that measurements and policies exist to protect: patients.

According to Dr. Cassel, patients — the consumers of the healthcare system — are now more than ever concerned about out-of-pocket costs, aware that hospitals are dangerous places and know that medical errors are a real possibility, no matter how remote. In this context, shared decision-making doesn't seem so far-fetched. "In this world where we're asking patients to engage in helping us with all kinds of healthcare improvement processes, we could ask them to diagnose with us. We could identify a part of the patient-doctor interaction during which this happens," she said.

From a physician perspective, shared decision-making means making an effort to debunk the myth of the physician knave through complete professionalism in prioritizing patient health. This includes having conversations about alternate treatment options, even if those options fail to bring more money into the system. Hearing options may get patients to question costs and benefits and, as Dr. Cassel noted, may lead away from algorithmic medicine and toward cognitive medicine.

Indeed, such a diagnostic tool that involves patients and gets the system to better outcomes more easily seems like it should be an easy sell. The number one reason for malpractice claims is misdiagnosis, so if there's a mechanism that improves diagnosis while acknowledging uncertainties and engaging and involving patients in the process, it may well be the way of the future.

Steady progress
This potentially powerful partnership faces a major obstacle: inaction. Dr. Cassel stressed the role of the individual physician and the specialty group in improving diagnostic medicine. "As of now, the NQF has no requests and no contracts from CMS for measures about diagnostic outcomes," she says. "That will only happen if the community asks for us. You could have a strong voice there. You could push us, even by submitting simple measures."

Dr. Cassel noted that process measures are not respected in the same way they once were because tracking outcomes has become increasingly important. While outcome measures have a well-deserved place, the move away from process measures means physicians lack information about where along the line an outcome may have become compromised. Without this knowledge, the science of improvement becomes difficult.

"In diagnostic medicine, process improvement might be a reasonable place to start," she said. "Diagnostic improvement can't continue to be 'too hard' to accomplish. We have to take a step into the process and see what we learn."

Many questions remain about how improving diagnosis should look. How are patients best involved? Which measurements are good, and what is their appropriate use? Which measurements are candidates for replacement? Dr. Cassel said that while physicians are constantly pressured to use evidence-based medicine, it's important to plan improvements in a way that allows adjustments, rather than waiting in a situation that is known to be inadequate. "Don't let the perfect be the end of the good," she said.

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