A team of researchers at Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center designed electronic triggers that helped them identify and reduce follow-up delays among patients currently being evaluated for colon or prostate cancer. The study, titled, “Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial” is available online in the Journal of Clinical Oncology.
“Our computerized triggers scanned huge amounts of patient data in the electronic health record and flagged individuals at risk for delays in follow-up of cancer-related abnormal clinical findings,” said Dr. Hardeep Singh, associate professor of medicine at Baylor and chief of health policy, quality & informatics program for the Center for Innovations in Quality, Effectiveness and Safety at the DeBakey Veterans Affairs Medical Center. “We created these trigger algorithms in the hopes of being able to leverage electronic health records to improve patient care and safety.”
The researchers defined a timely follow up as 30 days for suspected lung cancer, 60 days for colon cancer, and 90 days for prostate cancer. According to their analysis, a number of factors tend to cause delays in patients coming in for timely check ups, such as primary care workloads, time pressures and information overload, and lack of robust test result tracking systems.
“There are few, if any, human- or technology-based solutions that efficiently identify such care delays,” said Dr. Daniel Murphy, first author on the paper and instructor in the department of medicine and health services researcher at Baylor and the DeBakey Veterans Affairs Medical Center. “Triggers can act as safeguards as long as the information about potential delays can be communicated to clinicians taking care of these patients.”
Dr. Singh and his colleagues enlisted the help of 72 primary care physicians at two study sites throughout the 15-month study. The healthcare providers were grouped into intervention and control groups, wherein the latter had the physicians follow up suspicious findings through standard procedures, and the former used electronic triggers twice a month in all their patients.
These electronic triggers watch out for the following warning signs in patients that did not come in for a timely follow-up:
- Positive fecal occult blood test
- Iron deficiency anemia
- Elevated prostate specific antigen
- Abnormal imaging suspicious for cancer
“While all patients flagged by the computerized trigger algorithm in the intervention group are considered at risk, we confirmed the presence of delay by manually reviewing their records and communicating to their clinicians only when necessary,” Singh said.
“Patients seeing clinicians who were notified of potential delays had more timely diagnostic evaluation for both prostate and colon cancer,” Murphy said. “Also, more patients in the intervention part of the study had received diagnostic evaluation by the time we completed our final review.”
“Missed or delayed diagnoses are among the most common patient safety concerns in outpatient settings, and measuring and reducing them are a high priority,” said Singh, who also presented his team’s measurement work to the Institute of Medicine (IOM) last August. This fall, the IOM plans to release a comprehensive report on diagnosis related problems.
“Solutions that harvest and put to use the vast amount of electronic clinical data being collected are essential,” he said.
Dr. Singh thanks the following for their indispensable contributions to the study: Louis Wu and Ashely N.D. Meyer, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center; Eric J. Thomas, University of Texas Houston Medical School; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, Texas.