Measuring and Improving the Safety of Test Result Follow-Up

背景：电子健康记录(EHR)可以改善沟通过程，但具有独特的脆弱性 留下来。未能跟踪异常检测结果(“漏检结果”)是诊断中一个关键的可预防因素 VHA中的延迟，通常涉及基于电子病历的通信故障。我们的工作，以及来自 退伍军人事务部中的根本原因分析和医疗事故索赔，突出了许多技术和“社会”(即，工作流程， 组织、人员和政策)影响测试结果沟通和跟踪的变量。 目标：我们将制定和评估一项新的计划，以监督和改进测试结果- 相关的诊断安全性。这将包括制定、实施和评估变更包 (即，指导参与者改进的战略、改变概念和行动步骤的目录 努力识别和解决使卫生系统容易错过检测结果的风险。 特色与创新：在2017年全国质量论坛报告《提高诊断质量和 安全性“，提出了与检测结果跟踪相关的几个测量概念，以供进一步发展。 我们开发并测试了一种新颖的电子检测结果触发指示器系统，该系统使用 使用企业数据仓库(CDW)数据自动查找符合特定标准的患者。 触发器是可以识别伤害风险较高的患者并提醒提供者查看记录的信号 潜在的患者安全事件。我们的团队使用触发器来识别特定的数据模式，以便于选择 图表回顾。我们已经获得了合理的正预测值(PPV)和负预测值 (NPV)，并致力于在系统层面使用这些工具，以更有效地衡量护理延误。这 测量系统有可能成为一种近乎实时的监测系统，以识别患者的 测试结果可能被遗漏了。然而，使用CDW中的触发器来识别安全缺陷只是 第一步。为了使这些报告产生改进，团队(临床或组织基础)必须分析 并创建一个反馈系统，以产生学习和改进。我们的改革方案旨在 帮助退伍军人事务部设施团队实施监督和改进计划，确保安全 测量将转化为行动，并帮助他们创建备份系统来监控诊断延迟。 方法：与两个业务伙伴(NCPS和VA初级保健)合作，我们的具体目标是： 目标1：制定并试行“更改包”(SAFER更改包)，以提供退伍军人管理局设施指导 关于如何实施与漏检结果相关的监督和反馈计划。 目标2：评估“SAFER TRACK”干预措施(使用虚拟环境交付的SAFER变更包 突破性系列[VBTS]协作，辅以测试结果的自动监控数据)可以 使用阶梯式楔形整群随机对照试验减少遗漏结果。我们的结果衡量标准将是 漏检率，通过在全国范围内进行的随机人工病历审查来确定 作为VHA性能测量系统的一部分，以及漏检的自动“触发”指示器 结果。我们假设，在更安全的赛道期间，参与地点遗漏测试结果的情况将会减少 与干预前相比的干预。 目标3：通过混合方法评估更安全轨道干预措施的实施情况，以便 确定参与地点的优势和挑战。 我们的产出将包括多方面的社会技术工具和战略，以帮助预防、发现、缓解和 改善基于电子病历的沟通中的故障，这些故障经常导致VHA中的测试结果丢失。 意义：该项目是对《卫生服务数据和服务研究的定向征集》的响应 测量科学--一个学习型医疗保健系统倡议“以及高铁发展的主要优先领域 医疗保健信息学和创新使用信息技术改善诊断的子领域。

Background: Electronic health records (EHRs) can improve communication processes but unique vulnerabilities remain. Failure to follow-up abnormal test results (“missed results”) is a key preventable factor in diagnostic delays in the VHA and often involves EHR-based communication breakdowns. Our work, as well as data from root cause analyses and malpractice claims in the VA, highlights many technical and “social” (i.e., workflow, organizational, people, and policy) variables that affect test results communication and follow-up. Objectives: We will develop and evaluate a new program for surveillance and improvement of test results- related diagnostic safety. This will include development, implementation, and evaluation of a change package (i.e., a catalogue of strategies, change concepts, and action steps that guide participants in their improvement efforts15) that identifies and addresses risks that predispose health systems to missed test results. Unique features & Innovation: In a 2017 National Quality Forum report “Improving Diagnostic Quality and Safety”, several measurement concepts related to test results follow-up were proposed for further development. We developed and tested a novel electronic indicator system of triggers for missed test results, which uses automated methods to find patients meeting specific criteria using Corporate Data Warehouse (CDW) data. Triggers are signals that can identify patients at higher risk of harm and alert providers to review records for potential patient safety events. Our team has used triggers to identify specific data patterns to facilitate selective chart reviews. We have achieved reasonable positive predictive values (PPVs) and negative predictive values (NPVs), and aim to have these tools used at the system level to measure care delays more efficiently. This measurement system has the potential to become a near real-time surveillance system to identify patients whose test results might have been missed. However, identifying safety deficits using triggers within the CDW is only the first step. For these reports to result in improvements, a team (clinical or organization-based) must analyze the data and create a feedback system to generate learning and improvements. Our change package aims to help VA facility-based teams implement a surveillance and improvement program, ensure that safety measurement will translate into action and help them create back-up systems to monitor diagnostic delays. Methods: Working with 2 operational partners (NCPS and VA Primary Care), our specific aims are: Aim 1: Develop and pilot test a “change package” (SAFER Change Package) to provide VA facilities guidance on how to implement a surveillance and feedback program related to missed test results. Aim 2: Evaluate if the “SAFER TRACKS” Intervention (SAFER Change Package delivered using a Virtual Breakthrough Series [VBTS] Collaborative supplemented with automated surveillance data on test results) can reduce missed results using a stepped-wedge cluster-randomized control trial. Our outcome measures will be the rate of missed test results, determined through random manual medical record review conducted nationally as part of the VHA performance-measurement system, as well as automated `trigger' indicators of missed test results. We hypothesize there will be fewer missed test results in participating sites during the SAFER TRACKS Intervention as compared to during the pre-intervention period. Aim 3: Evaluate the implementation of the SAFER TRACKS Intervention through mixed-methods in order to determine strengths and challenges at participating sites. Our outputs will include multifaceted socio-technical tools and strategies to help prevent, detect, mitigate, and ameliorate breakdowns in EHR-based communication that often lead to missed test results in the VHA. Significance: The project is responsive to “Targeted Solicitation for Health Services Research on Data and Measurement Sciences – A Learning Health Care System Initiative” and to HSR&D's Major Priority Domain of Healthcare Informatics and Sub-domain for innovative uses of information technology to improve diagnosis.