Electronic health record-based triggers to detect potential delays in cancer diagnosis

Abstract

BackgroundDelayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate ‘trigger’ algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis.MethodsWe mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV).ResultsThe PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.ConclusionsEHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.

Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism

“…23,33 Future prospective application of the TSH trigger algorithm can be used by clinical teams as a surveillance and quality improvement technique to monitor and improve follow-up.…”

“…Trigger-positive patient records were reviewed by a physician using a manual data collection instrument developed based on previous work on trigger development and evaluation. 23,24,33 The reviewer (AA) used the review instrument to evaluate whether a delay was truly experienced by the patient, collect reasons for false-positive results, and determine patient and provider characteristics that potentially impacted delays. Characteristics included patient age; gender; race; presence of comorbidities including diabetes, hypertension, hyperlipidemia, obesity, and depression; type of provider seen when being tested for the TSH results (primary care provider [PCP] vs. specialist); who was primarily managing the patient's thyroid disease (PCP vs. an endocrinologist); what type of PCP the patient regularly saw (physician vs. nurse practitioner or physician's assistant); and whether the patient had previous PCP or endocrine visits.…”

“…We found that positive predictive values (PPVs) of the trigger algorithms were all >50%, which appears promising for real-world application. 23 EHR triggers can thus automatically identify medical records at risk for delayed follow-up of abnormal test results and facilitate timely follow-up action. 24 Thyroid-stimulating hormone (TSH) test results can often be missed or delayed for follow-up, 25 leading to suboptimal patient outcomes.…”

Prostate Cancer Screening

“…For patients who choose to be screened, EHRs can be used to automatically flag patients who screen positive and require follow-up. 50 …”

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review

“…Similarly, symptom-disease pair analysis of large administrative data sets has been used to identify incorrect diagnoses after ER "treat-andrelease" visits [12]. EHR-based triggers also can be used prospectively by enabling EHRs to provide "red flags" when there is a delay in the follow-up of abnormal test results [13]. Likewise, the Kaiser Permanente Southern California Outpatient Safety Net Program leverages electronic health information to identify and address a variety of potential care gaps for different clinical conditions, including potentially missed diagnoses (e.g.…”