It's time to end diagnosis fragmentation

We've all heard about, discussed and lamented fragmentation of care. You know the scenario: A patient has 24 medications managed by eight separate subspecialists, gets multiple duplicative imaging studies ordered by different teams in different health systems at different imaging centers--all the while leaning on their primary care physician to organize and manage the mishmash of physician-to-physician correspondence (or lack thereof) to ensure the proper steps are taken to actually improve their state of health. Meanwhile, a patient with the same condition in a neighboring city is treated entirely differently.

There is no need to reiterate all the reasons this does not work.

Fortunately, a substantial amount of effort is being put into reforming the way patients are treated. Efficiency and efficacy are primary goals of modern healthcare. Surgeon and journalist Atul Gawande has eloquently written about standardization and systematic implementation of care for patients with certain diagnoses (such as osteoarthritis of the knee), and how length of stay decreases, costs decrease, and outcomes improve. Harvard Business School professor Michael Porter continues to push the concept of "Integrated Practice Units" which are multi-disciplinary teams organized around certain conditions (or closely related conditions), responsible for the full-cycle of care, and measure outcomes for every patient--therefore implementing constant feedback, learning, and improvement in how patients with certain conditions are treated. The bottom line? Many smart people have laid the grounds and drawn the map for the future direction of medical treatment

But what about diagnosis? How do we know that patients who need knee replacements have osteoarthritis and not (although much more rare) rheumatoid arthritis? How do we know that the child who needs surgery has appendicitis, and not a Meckel's diverticulum? There are many centers across the nation with excellent, streamlined, systematic cardiac and cancer care; but how did they find out their patients had heart disease or cancer in the first place? Diagnosis is expensive for our healthcare system. It is anxiety-provoking for our patients. Yet, we haven't spent much time analyzing how patient symptoms are transferred to diagnosis.

In many (and most) cases, our approach to diagnosis has, unfortunately, been haphazard. The number, type and order of diagnostic tests often is very different, depending on if a patient is first seen in a primary care office or an emergency room. A patient's work-up may primarily be driven by which service admits a patient, or which subspecialty is consulted first (before a definitive diagnosis is made). A hedgy suggestion from a radiologist for additional testing or confusing interpretation from a pathologist may lead to extra, unhelpful tests. I'm confident that if we studied how patients who present with dyspnea, hematemesis, and abdominal pain were "worked-up" in varying health systems across the nation (or even just in individual cities), we'd find enormous variation and huge cost and outcome discrepancies.

It is time for multi-disciplinary, diagnosis-focused teams. The lack of communication between multiple services participating in a patient's diagnosis decreases accuracy and precision, and escalates the likelihood of the increasingly expensive "wrong-diagnosis."

Radiologists and pathologists certainly are diagnostic-centric specialists who should lead this charge. But every specialty has diagnostic experts. Our GI and cardiology colleagues are examples of other subspecialty physicians that also are experts in diagnosis via modalities such as optics/endoscopy and echocardiography.

Barriers separating diagnostic subspecialties need to be broken. Conversations between diagnostic experts need to begin. Multi-disciplinary diagnosis-focused teams must be formed.

If patients could be referred to teams like this, the process for diagnosing ailments could be standardized with increasing efficacy, decreasing cost and improved efficiency. Systematic processes for diagnosing patients with dyspnea, hematemesis and abdominal pain could be established, rather than the diagnostic process being determined by which service was consulted first, or by established traditions at the hospital a patient visits.

As we continue to end fragmentation of treatment in our healthcare system, let's also begin ending the fragmentation of diagnosis.

Matt Hawkins, M.D., is a vascular interventional radiology fellow at the University of Washington/Seattle Children's Hospital. Follow him on Twitter at @MattHawkinsMD.

Prior articles by the author:
RSNA13: Business analytics, clinical decision support take center stage for radiologists

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