A decade’s worth of malpractice claims data allowed three Phoenix-based ED groups to improve care of spinal epidural abscess patients.
Each group had captive insurance, and decided to share their claims data. “What we started doing was aggregating our data over a decade’s worth of claims,” says Terrence Brown, MD, JD, FACEP. At the time, Brown was counsel to the Emergency Physicians Insurance Program, and ED chairman for Banner Estrella Medical Center.
The claims data included both actual malpractice lawsuits and incidents in which there was the potential for litigation. “If there was an adverse event, or if a provider thought there was an opportunity to improve care, they would let us know about it,” Brown says.
By pooling their data, the ED groups figured out the true prevalence of claims. “What first appeared to be a handful of claims involving outlier behavior turned out to have some common themes,” Brown notes.
Spinal epidural abscess is not a common diagnosis, and it is a difficult one to make. “When there is a bad case, it’s usually very high-dollar litigation, potentially millions of dollars,” Brown explains.
Taken as a whole, the claims showed EPs often were on the right diagnostic track. They were considering a spinal cord emergency or a spinal infection. The problem was they did not image the entire spine. “When we started looking at the cases, we would see that the EP concluded too early that the patient didn’t have the diagnosis, because they didn’t get a complete workup,” Brown reports.
For instance, EPs would order a lumbar spine MRI for a patient with low back pain and leg weakness. “But, in fact, [patients] had pathology at multiple levels, and it’s not until they have a full neurosurgical evaluation that the pathology is appropriately detected,” Brown explains.
Patients were discharged from the ED, only to bounce back with worsening symptoms. The EP then would image the entire spine, revealing the pathology that was not seen in the previous MRI. “Clinical literature is now making it more evident that you need to image the entire spine,” Brown adds.
The ED groups implemented an MRI cord compression screen protocol. When EPs are ordering emergent MRIs of a single level of the spine, the system alerts the EP that it is not sufficient to rule out a spinal cord emergency. It prompts the EP to order a new MRI order set, as well as antibiotics, blood cultures, and early neurosurgical consult. “It pooled all the other things you tend to not necessarily remember when you are in the midst of an emergency,” Brown says.
The claims data helped the ED groups secure buy-in from radiology. “What made it easier to sell this idea was being able to show that these kinds of errors happen more frequently than we might realize,” Brown says.
Looking at the data in aggregate made a bigger impression than only hearing about one of these cases once in a while. “Instead of just saying, ‘We had a bad case,’ we instead could say, ‘We are all seeing the same pattern,’” Brown offers.
EPs can make diagnoses for spinal epidural abscess and other cord emergencies faster. “It forces the clinician early on to look for multilevel pathology. It saves everybody time, and, ultimately, is better for the patients,” Brown says.
Every ED has somewhat unique risks in terms of malpractice, Brown notes. Some handle many claims regarding certain diagnoses; others handle a high percentage of missed over-reads by radiology.
“But when it comes to the more common claims, spinal epidural abscess or subarachnoid hemorrhage or stroke, the common theme that doesn’t change is diagnostic error,” Brown stresses. Without data, EDs cannot know how they are performing compared to peers. “There’s a tendency to presume they’re doing a better or worse job than they actually are. In reality, if you look at claims data from other systems, you can see that the patterns are the same,” Brown observes.
This suggests malpractice risks are tied to cognitive errors all EPs make. “When you’re able to show that it’s not just our health system, but rather it’s a cognitive error we are all prone to make, it’s a little easier to get people to buy into change,” Brown offers.
Institutions remain wary of opening their malpractice claims data to external scrutiny or research. “You have to have a health system and risk management department that’s interested in getting over the fear that the data will be used against them in some way,” Brown says. More health systems are trying to use malpractice data for quality improvement, Brown notes. States vary as to whether the information is going to be legally discoverable during litigation. “Depending on what legal protections you have, there is a risk, still, when you are looking at this data, that it can be used by a plaintiff attorney to prove negligence,” Brown says.
Nonetheless, health systems are moving toward more transparency with claims data. “The benefits of preventing litigation down the road are probably worth the potential costs associated with this information being used in current litigation,” Brown shares.
ED providers, ED groups, health systems, and insurers first need to become comfortable their malpractice claims data will not be used against them. “People are thinking differently about the information, instead of keeping it bottled up in a risk management silo for years,” Brown adds.