Health informatics approaches to reduce missed opportunities in diagnosis of pancreatic cancer

背景资料。胰腺癌是一种高度致命的癌症，在退伍军人中的发病率不断上升。 早期诊断提供了最好的生存机会，然而只有30%的患有胰腺癌的退伍军人被诊断出来 在早期阶段。我们的建议侧重于优化临床结果具有提示意义的患者的早期诊断 通过识别和减少错过的机会而面临延迟诊断的风险的胰腺癌 在诊断中(MODS)。多器官功能障碍定义为事后判断表明可供选择的情况 决定或行动本可以导致更及时的诊断。 重要性/影响力。该提案以退伍军人事务部HSR&D质量和研发优先领域为中心 安全和医疗保健信息学。几乎没有系统性的努力来提高退伍军人癌症护理的质量 患有胰腺癌。这项提案是第一批大规模检查这些患者护理差距的努力之一。 病人。我们建议开发电子触发工具，当实施时，将有可能识别 可能错过启动或完成早期胰腺癌诊断过程的机会 诊断。我们的结果也将作为开发基于信息学的诊断工具的基础 其他高危疾病，包括其他癌症类型。 创新。开发新的决策支持工具(电子触发器)，以减少诊断延迟 胰腺癌是第一个以胰腺癌治疗为中心并围绕 星座或“红旗”的组合，而不是像以前所有关于这一主题的著作中那样，只有一个“红旗”。 我们的研究在概念上也是创新的，因为它代表了将电子触发器工具转移到 减少胰腺癌从研究环境到临床环境的诊断延迟。 明确的目标。我们的目标是改善胰腺癌的诊断过程，通过开发 有效的决策支持工具。我们有三个目标。目标1：找出胰腺癌错失的机会 诊断。目标2：开发电子算法(即电子触发工具)以识别高危退伍军人 可能错失了诊断胰腺癌的机会。目标3：进行电子学习的形成性评估 触发工具，以指导未来的测试和在临床实践中的实施。 方法论。在目标1中，我们将从已经存在的 建立了国家VA队列，对他们的医疗记录进行结构化审查，以确定频率和类型 MODS以及与这些错失的机会相关的关键患者、提供者和系统特定因素。在……里面 目标2，基于目标1的发现和文献中已知的，我们将开发最多5个电子触发器 通过自动识别特定模式来识别潜在MODS高危患者的工具 临床电子健康档案数据。在目标3中，我们将通过利益相关者进行形成性评估 与退伍军人、医疗保健提供者和运营人员进行访谈，以确定障碍和促进者 在临床实践中实施开发的电子触发器，以及许多社会技术因素。 实施/后续步骤。拟议的研究将开发医疗保健信息学工具，以确定 需要诊断的高危患者亚群中早期诊断胰腺癌的机会 评估。在接下来的步骤中，我们将检查我们的信息学工具(电子触发器工具)的有效性，以改进 通过混合型I型有效性实施研究对退伍军人管理局胰腺癌护理质量的影响。这 多学科研究，以及职业发展和指导计划，将增加对早期知识的了解 在退伍军人事务部获得癌症诊断机会，并增强我过渡到独立医疗服务的能力 具有医疗保健信息学专业知识的研究人员。退伍军人管理局是美国最大的癌症护理机构， 从而为开发和实施优化诊断流程的新方法提供理想环境 癌症护理。

Background. Pancreatic cancer is a highly lethal cancer with increasing incidence among Veterans. Early diagnosis offers the best chance of survival, yet only 30% of Veterans with pancreatic cancer are diagnosed at early stages. Our proposal focuses on optimizing early diagnosis of patients with clinical findings suggestive of pancreatic cancer who are at risk for delayed diagnosis through identifying and reducing missed opportunities in diagnosis (MODs). MODs are defined as instances in which post-hoc judgement indicates that alternative decisions or actions could have led to a more timely diagnosis. Significance/Impact. This proposal is centered around the VA HSR&D priority areas of quality and safety and health care informatics. There are few systematic efforts to improve quality of cancer care for Veterans with pancreatic cancer. This proposal is one of the first large-scale efforts to examine the gaps in care for these patients. We propose to develop electronic trigger tools that, when implemented, will have the potential to identify possible missed opportunities to either initiate or complete the diagnostic process for earlier pancreatic cancer diagnosis. Our results will also serve as foundational for developing informatics-based diagnosis tools for several other high-risk conditions, including other cancer types. Innovation. The development of novel decision support tools (e-triggers) to reduce diagnostic delays in pancreatic cancer represents the first e-trigger tool that is centered on pancreatic cancer care and built around a constellation or combination of “red flags” as opposed to a single “red flag” as in all prior works on the topic. Our study is also conceptually innovative because it represent a first step towards moving e-trigger tools to reduce diagnostic delays in pancreatic cancer from the research environment into the clinical setting. Specific Aims. Our goal is to improve the diagnostic process for pancreatic cancer by developing effective decision support tools. We have 3 aims. Aim 1: To identify missed opportunities for pancreatic cancer diagnosis. Aim 2: To develop electronic algorithms (i.e., e-trigger tools) to identify high-risk Veterans with potential missed opportunities for pancreatic cancer diagnosis. Aim 3: To conduct a formative assessment of e- trigger tools to guide future testing and implementation in clinical practice. Methodology. In Aim 1, we will randomly select 500 pancreatic cancer cases from an already established national VA cohort for structured review of their medical records to identify the frequency and types of MODs as well as key patient-, provider-, and system-specific factors linked to these missed opportunities. In Aim 2, based on the findings of Aim 1 and what is known from the literature, we will develop up to 5 e-trigger tools to identify patients at high-risk for potential MODs through automated identification of specific patterns in clinical electronic health record data. In Aim 3 we will perform formative assessment through stakeholder interviews with Veterans, health care providers, and operational personnel to identify barriers and facilitators to implementing developed e-triggers in clinical practice, as well as a host of socio-technical factors. Implementation/Next Steps. The proposed research will develop health care informatics tools to identify opportunities for earlier pancreatic cancer diagnosis among high-risk patient subgroups who warrant diagnostic evaluation. In the next steps, we will examine the effectiveness of our informatics tools (e-trigger tools) to improve quality of pancreatic cancer care in the VA through a hybrid type I effectiveness-implementation study. This multidisciplinary research, along with career development and mentoring plans, will increase knowledge of earlier cancer diagnosis opportunities in the VA and enhance my ability to transition to an independent health services researcher with expertise in health care informatics. The VA is the largest provider of cancer care in the U.S., thus providing the ideal setting for developing and implementing new ways to optimize diagnostic processes in cancer care.