Development and validation of electronic health record-based triggers to detect delays in follow-up of abnormal lung imaging findings1

Radiology

Volumn 277, Issue 1, 2015, Pages 81-87

  Murphy, Daniel R ^a,b   Thomas, Eric J ^c,d   Meyer, Ashley N D ^a,b   Singh, Hardeep ^a,b  

^a MICHAEL E DEBAKEY VETERANS AFFAIRS MEDICAL CENTER   (United States)

^b BAYLOR COLLEGE OF MEDICINE   (United States)

^c UNIVERSITY OF TEXAS MEDICAL SCHOOL   (United States)

^d UT Memorial Hermann Center for Healthcare Quality and Safety   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ALGORITHM; ARTICLE; COMPUTER ASSISTED TOMOGRAPHY; DELAYED DIAGNOSIS; ELECTRONIC MEDICAL RECORD; FALSE POSITIVE RESULT; HUMAN; IMAGE ANALYSIS; IMAGE QUALITY; LUNG CANCER; MAJOR CLINICAL STUDY; PREDICTIVE VALUE; PRIORITY JOURNAL; RETROSPECTIVE STUDY; THORAX RADIOGRAPHY; VALIDITY; ADULT; AGED; ELECTRONIC HEALTH RECORD; FEMALE; FOLLOW UP; LUNG TUMOR; MALE; MIDDLE AGED; RADIOGRAPHY; VALIDATION STUDY;

ADULT; AGED; ALGORITHMS; DELAYED DIAGNOSIS; ELECTRONIC HEALTH RECORDS; FEMALE; FOLLOW-UP STUDIES; HUMANS; LUNG NEOPLASMS; MALE; MIDDLE AGED; RETROSPECTIVE STUDIES; TOMOGRAPHY, X-RAY COMPUTED;

EID: 84942446637     PISSN: 00338419     EISSN: 15271315     Source Type: Journal    
DOI: 10.1148/radiol.2015142530     Document Type: Article

References (43)

1. Singh H, Sethi S, Raber M, Petersen LA. Errors in cancer diagnosis: current understanding and future directions. J Clin Oncol 2007;25(31):5009-5018.
2. Singh H, Hirani K, Kadiyala H, et al. Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. J Clin Oncol 2010;28(20):3307-3315.
3. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006;145(7): 488-496.
4. Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care 2004; 13(2):121-126.
5. Brenner RJ, Lucey LL, Smith JJ, Saunders R. Radiology and medical malpractice claims: a report on the practice standards claims survey of the Physician Insurers Association of America and the American College of Radiology. AJR Am J Roentgenol 1998;171(1):19-22.
6. Berlin L, Murphy DR, Singh H. Breakdowns in communication of radiological findings: an ethical and medico-legal conundrum. Diagnosis 2014;1(4):263-268.
7. Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. J Gen Intern Med 2012; 27(11):1416-1423.
8. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165(13):1493-1499.
9. Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf 2012;21(1):30-38.
10. Murphy DR, Reis B, Sittig DF, Singh H. Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med 2012; 125(2):209.e1-e7.
11. Murphy DR, Reis B, Kadiyala H, et al. Electronic health record-based messages to primary care providers: valuable information or just noise? Arch Intern Med 2012;172(3): 283-285.
12. McDonald CJ, McDonald MH. Electronic medical records and preserving primary care physicians' time: comment on "electronic health record-based messages to primary care providers". Arch Intern Med 2012;172(3): 285-287.
13. Murphy DR, Singh H, Berlin L. Communication breakdowns and diagnostic errors: a radiology perspective. Diagnosis 2014;1(4): 253-261.
14. Menon S, Smith MW, Sittig DF, et al. How context affects electronic health recordbased test result follow-up: a mixed-methods evaluation. BMJ Open 2014;4(11):e005985.
15. Al-Mutairi A, Meyer AND, Chang P, Singh H. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. J Am Coll Radiol 2015;12(4):385-389.
16. Frankovich J, Longhurst CA, Sutherland SM. Evidence-based medicine in the EMR era. N Engl J Med 2011;365(19):1758-1759.
17. Szekendi MK, Sullivan C, Bobb A, et al. Active surveillance using electronic triggers to detect adverse events in hospitalized patients. Qual Saf Health Care 2006;15(3): 184-190.
18. Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011; 30(4):581-589.
19. Jha AK, Classen DC. Getting moving on patient safety: harnessing electronic data for safer care. N Engl J Med 2011;365(19):1756-1758.
20. Zalis M, Harris M. Advanced search of the electronic medical record: augmenting safety and efficiency in radiology. J Am Coll Radiol 2010;7(8):625-633.
21. Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003;12(Suppl 2):ii39-ii45.
22. Honigman B, Light P, Pulling RM, Bates DW. A computerized method for identifying incidents associated with adverse drug events in outpatients. Int J Med Inform 2001;61(1):21-32.
23. Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients: 1991. Qual Saf Health Care 2005;14(3):221-225; discussion 225-226.
24. Mull HJ, Nebeker JR. Informatics tools for the development of action-oriented triggers for outpatient adverse drug events. AMIA Annu Symp Proc 2008 Nov 6:505-509.
25. Knirsch CA, Jain NL, Pablos-Mendez A, Friedman C, Hripcsak G. Respiratory isolation of tuberculosis patients using clinical guidelines and an automated clinical decision support system. Infect Control Hosp Epidemiol 1998;19(2):94-100.
26. Muething SE, Conway PH, Kloppenborg E, et al. Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. Qual Saf Health Care 2010; 19(5):435-439.
27. Murphy DR, Laxmisan A, Reis BA, et al. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf 2014;23(1):8-16.
28. Singh H, Thomas EJ, Mani S, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med 2009;169(17):1578-1586.
29. Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc 2007;14(4):459-466.
30. Veteran Population. National Center for Veterans Analysis and Statistics. http://www. va.gov/vetdata/Veteran-Population.asp. Accessed December 11, 2014.
31. Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff (Millwood) 2013;32(8):1368-1375.
32. Poon EG, Haas JS, Louise Puopolo A, et al. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med 2004;19(4):316-323.
33. Gordon JRS, Wahls T, Carlos RC, Pipinos II, Rosenthal GE, Cram P. Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record. Ann Intern Med 2009;151(1):21-27, W5.
34. Schiff GD, Kim S, Krosnjar N, et al. Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. Arch Intern Med 2005;165(5):574-577.
35. Hunnibell LS, Rose MG, Connery DM, et al. Using nurse navigation to improve timeliness of lung cancer care at a veterans hospital. Clin J Oncol Nurs 2012;16(1): 29-36.
36. Hunnibell LS, Slatore CG, Ballard EA. Foundations for lung nodule management for nurse navigators. Clin J Oncol Nurs 2013;17(5):525-531.
37. McMullen L. Oncology nurse navigators and the continuum of cancer care. Semin Oncol Nurs 2013;29(2):105-117.
38. Choksi VR, Marn CS, Bell Y, Carlos R. Efficiency of a semiautomated coding and review process for notification of critical findings in diagnostic imaging. AJR Am J Roentgenol 2006;186(4):933-936.
39. Powell AA, Schultz EM, Ordin DL, et al. Timeliness across the continuum of care in veterans with lung cancer. J Thorac Oncol 2008;3(9):951-957.
40. Gould MK, Ghaus SJ, Olsson JK, Schultz EM. Timeliness of care in veterans with non-small cell lung cancer. Chest 2008;133(5):1167-1173.
41. Smith M, Murphy D, Laxmisan A, et al. Developing software to "track and catch" missed follow-up of abnormal test results in a complex sociotechnical environment. Appl Clin Inform 2013;4(3):359-375.
42. Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf 2010;36(5):226-232.
43. Nebeker J, Stoddard G, Rosen A. Considering Sensitivity and Positive Predictive Value in Comparing the Performance of Triggers Systems for Iatrogenic Adverse Events: Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting. Rockville, Md: Agency for Healthcare Research and Quality, 2009.