In a recent study published in the Journal of Clinical Oncology, a team of researchers from the Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center developed an electronic trigger to search for key data that is able to detect and reduce follow-up delays for patients being assessed for a diagnosis of prostate or colon cancer.
“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.”
Delayed cancer diagnosis is the most common reason for ambulatory malpractice claims and is associated with patient anxiety and potentially poorer clinical outcomes. These delays often result from a variety of cognitive and system factors that lead to lack of timely evaluation of red flag signs and symptoms or abnormal test results. Despite increasing adoption of electronic health records (EHRs) and greater access to diagnostic information, delays persist in part because of failure to receive, recognize, or process critical patient information. Thus, interventions are needed to support front-line providers.
In the study, the team of researchers defined timely follow-up as 90 days for prostate cancer, 60 days for colon cancer and 30 days for suspected lung cancer. According to Singh, time pressures and information overload, primary care workloads, and lack of robust test result tracking systems can lead to delays in the evaluation of patients whose original test results suggested cancer.
“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.”
The researchers recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from 2011 and 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation.
Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger and prostate trigger but not the lung trigger. More intervention patients than control patients received diagnostic evaluation by final review.
“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.”
The research team is now working to refine and explore trigger application in other settings to detect and monitor delays and improve timeliness of cancer diagnoses.
“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.