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VA research in action

New tools to reduce delays in diagnosing cancer

November 21, 2018

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Photo: ©iStock/Martin Prescott

Early diagnosis of certain types of cancer makes successful treatment more likely. Patients play an important role in early diagnosis. Beyond knowing the signs and symptoms of different cancers, following up on tests and procedures can  improve their chances of earlier diagnosis  when the cancer may  still be treatable.

Clinicians can help improve timeliness of their patients’ diagnosis. In addition to facilitating prompt appointment times for symptom evaluation, timely referrals for tests and treatments are also essential. A team led by researchers at the Michael E. DeBakey VA Medical Center in Houston and the Baylor College of Medicine recently found that, for five common cancers (colorectal, bladder, lung, hepatocellular, and breast) clinicians sometimes did not act promptly on abnormal test results that may suggest the presence of  cancer.

The team found several reasons these test results might have been missed:  a lack of knowledge or training on the part of some providers; ambiguous follow-up policies; and the fact that providers received many unnecessary  alert notifications in their electronic health records, resulting in an inability to screen out those needing to be acted upon promptly.

They developed a set of electronic queries, or “triggers,” for use within VA’s electronic health record system (EHR) to find Veterans whose records showed evidence of possible delays in care. They tested these triggers by querying the EHR database to find partial lists of Veterans who may not have received timely follow up and then checked medical records of these patients to confirm if they did. In the majority of cases, something had fallen through the cracks.

For each of the cancers they studied, the team devised different tools to obtain information. Team members are now working with teams at other VA facilities to show them how to use the EHR database  to extract data that can then be used to improve the care they provide to Veterans. At least five facilities have signed on to test the tools starting in 2019.  Researchers  are also working to develop performance standards to measure how long it takes facilities to follow up on significant test results and are studying how the trigger information can best be communicated to those who need to take action.

The team is also developing, or has developed, other tools to keep abnormal test results from falling through the cracks for VA patients and others. Some examples include:

  • SAFER Guides, designed to enable health care organizations to self-assess several aspects of safety within the context of EHR use;
  • A toolkit that offers practical guidance on the timely communication of test results to providers and patients;
  • Ten strategies to help providers manage EHR alerts through better alert routing, prioritization, and visualization
  • Eight recommendations for policies health care organizations should use to communicate test results.

VA has revised its national policy (VHA Directive 1088) on communicating test results to providers and patients with input from the research team and other stakeholders.  In addition to developing national standards for timely communication, the policy now offers guidance on several best practices VA facilities should consider adopting.

Veterans, too, have a role. The team suggests that all Veterans should sign up for and use myHealtheVet, VA’s patient and caregiver health care portal, to regularly review their clinical information, including the results of tests they have taken. The researchers stress that if patients have not heard from someone within a week or two after testing, they should call their providers!

Principal investigator: Dr. Hardeep Singh, Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston.

Selected publications and additional information:

Murphy, DR, Meyer AND, Sittig DF, Meeks DW, Thomas EJ, Singh H. Application of electronic trigger tools to identify targets for improving diagnostic safety. BMJ Qual Saf, published online first, 5 Oct 2018

Murphy DR, Meyer AND, Vaghani V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Electronic triggers to identify delays in follow-up of mammography; harnessing the power of Big Data in health care. J Am Coll Radiol. 2018 Feb;15(2):287-295.

Murphy DR, Meyer AND, Vaghani V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Development and validation of trigger algorithms to identify delays in diagnostic evaluation of gastroenterological cancer. Clin Gastroenterol Hepatol. 2018 Jan;16(1):90-98.

Murphy DR, Meyer AND, Vaghani V, Russo E, Sittig DF, Richards KA, Wei L, Wu L, Singh H. Application of electronic algorithms to improve diagnostic evaluation of bladder cancer. Appl Clin Inform, 2017 Mar 22;8(1):279-290.

Murphy DR, Meyer AND, Bhise V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Computerized triggers of Big Data to detect delays in follow-up of chest imaging results. Chest, 2016 Sep;150(3):613-20.

Murphy DR, Laxmisan A, Reis BA, Thomas EJ, Esquivel A, Forjuoh SN, Parikh R, Khan MM, Singh H. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf, 2014 Jan;23(1):8-16.

HSRD Study: Automated point-of-care surveillance of outpatient delays in cancer diagnosis


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