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A learning health system approach to improve diagnosis

Although recent studies show that misdiagnosis affects at least one in 20 U.S. adults each year, health systems have yet to develop a systematic approach to measure and improve diagnostic performance. At Geisinger, the Committee to Improve Clinical Diagnosis works with the Safer Dx Learning Lab to address this challenge.

Diagnostic errors – missed opportunities to make timely and accurate diagnoses – are hard to tackle because they are difficult to identify and measure. The 2015 National Academy of Medicine (NAM, formerly IOM) report entitled “Improving Diagnosis in Health Care” highlights the necessity and significance to improve the diagnostic process. Different studies indicate that 10-30% of all medical errors are related to errors in diagnosis. The NAM estimates that most Americans will experience a diagnostic error at least once in their lifetime. The Agency for Health Research and Quality (AHRQ) considers improving diagnosis as the next great frontier in the patient safety improvement movement. In May 2019, the AHRQ, named diagnostic errors as one of the three “critical challenges that are front and center in today’s ever-changing digital healthcare ecosystem”.

We have a professional and moral imperative to address this formidable challenge.

At Geisinger, the Committee to Improve Clinical Diagnosis (CICD) was established as a work group in 2014 to develop innovative approaches to identifying and addressing diagnostic errors. Today, the committee has representation from all major disciplines and includes many senior clinical directors, operational leaders and key stakeholders. It is chaired by Dennis Torretti, MD, associate CMO, Geisinger Medical Center and chairman emeritus of the Division of Medicine at Geisinger.  

As a result of the work of the committee, potential diagnostic opportunities are reviewed, shared with departments, and learning opportunities are identified. Constructive feedback is completed when appropriate and any system issues that may impact diagnostic safety are identified. Lessons learned are shared broadly in an open, transparent, and constructive fashion. 

Committee to Improve Clinical Diagnosis

Committee members

Amit Bansal, MD, MBA
Director, Department of Hospital Medicine, Central Region, Geisinger
Clinical Associate Professor of Medicine, Geisinger Commonwealth School of Medicine 

Keith Boell, DO
Quality Director, Geisinger Medicine Institute
Medical Director, Quality and Innovation, Geisinger Health Plan

Jay Bringman, MD
Associate Chief Quality Officer, Geisinger Medical Center
Vice Chair and Quality Director, Women’s Health Service Line, Geisinger 

Greg Burke, MD
Chief Patient Experience Officer, Geisinger 

Ross Ellison, MD
Director of Geisinger Placement Services
Emergency Medicine Physician, Geisinger
 

Michael Fitzpatrick, MD
Co-Chair, Department of Emergency Medicine, Geisinger
Director, Department of Emergency Medicine, Geisinger Medical Center

Benjamin Hohmuth, MD, MPH
Chief Medical Informatics Officer, Geisinger 

Jennifer Hunt, BSN, RN, RNFA
Quality Coordinator, Safer Dx Learning Lab, Geisinger

Lauren Adrienne Johnson-Robbins, MD
Quality Director, Pediatrics, Geisinger Medical Center

Maria Kobylinski, MD
Chair, Community Medicine, Geisinger Medicine Institute 

Saritha Korukonda, MD, MS
Project Manager, Safer DX Learning Lab, Geisinger

Patricia Lamphear, RN, JD, CPHRM 
Director, Risk Management & Patient Safety

Gerald Maloney, MD
Chief Medical Officer, Geisinger System Hospitals

Kyle Marshall, MD
Emergency Medicine Physician and Informatician, Geisinger 

Yatin Mehta, MD
Associate, Pulmonary and Critical Care Medicine

Eric Newman, MD
Director of Quality and Innovation, Geisinger Medicine Institute 
Associate, Department of Rheumatology, Geisinger 

Rajiv Panikkar, MD
Chair, Geisinger Cancer Institute 

Aalpen Patel, MD
Chair, Geisinger Radiology

Anthony Petrick, MD
Director, Division of Bariatric and Foregut Surgery, Geisinger
Quality Director, Geisinger Surgical Institute

David Rolston, MD
Chair, Department of Medicine Specialties
Director, Division of General Internal Medicine, Geisinger Medical Center

Conrad Schuerch, MD
Chairman Emeritus, Geisinger Laboratory Medicine

Greg Strevig
Vice President, Enterprise Analytics, Geisinger

Michelle Thompson, MD
Associate Chief Academic Officer, Graduate Medical Education, Geisinger Commonwealth School of Medicine 

Dennis Torretti, MD (Chair)
Associate Chief Medical Officer, Geisinger Medical Center
Chairman Emeritus, Department of Medicine, Geisinger

Divvy Upadhyay, MD, MPH
Researcher-In-Residence, Safer Dx Learning Lab, Geisinger
Scientist, Division of Quality and Safety, Geisinger

Jennifer Vodzak, MD
Pediatric Infectious Diseases Specialist, Geisinger


doctors looking at computer

“We have developed a Committee to Improve Clinical Diagnosis to target vulnerabilities in the diagnostic process and sustain a culture of diagnostic excellence.” 

Dr. Dennis Torretti, associate chief medical officer, Geisinger