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，但存在独特的漏洞 保持。未能随访异常检测结果（“漏诊结果”）是诊断中的一个关键可预防因素， VHA中的延迟，通常涉及基于EHR的通信故障。我们的工作，以及来自 VA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进的变量。 目标：我们将开发和评估一个新的监测和改进测试结果的计划- 相关的诊断安全。这将包括制定、实施和评估一揽子改革方案 (i.e.,指导参与者改进的战略、变革概念和行动步骤目录 努力15），以确定和解决风险，使卫生系统容易错过测试结果。 独特的功能和创新：在2017年国家质量论坛报告“提高诊断质量和 安全性”，提出了几个与测试结果跟踪相关的测量概念，以供进一步开发。 我们开发并测试了一种新型的电子指示器系统，用于触发遗漏的测试结果， 使用公司数据仓库（CDW）数据自动化方法查找符合特定标准的患者。 触发器是可以识别处于较高伤害风险的患者并提醒提供者审查记录的信号， 潜在患者安全事件。我们的团队使用触发器来识别特定的数据模式，以促进选择性的 图表评论。我们已经达到了合理的阳性预测值（PPV）和阴性预测值 （NPVs），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迟。这 测量系统有可能成为一个近实时的监测系统，以确定患者， 测试结果可能会被遗漏。然而，使用CDW中的触发因素识别安全缺陷仅 第一步为了使这些报告得到改进，团队（临床或组织）必须分析 数据，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， 测量将转化为行动，帮助他们建立备用系统，以监测诊断延误。 方法：与2个运营伙伴（NCPS和VA Primary Care）合作，我们的具体目标是： 目标1：开发并试点测试“变更包”（SAFER变更包），为VA设施提供指导 如何实施与遗漏测试结果相关的监督和反馈计划。 目标2：评估“安全跟踪”干预（使用虚拟 突破系列[VBTS]协作补充自动化监测数据的测试结果）可以 使用阶梯楔形分组随机对照试验减少遗漏结果。我们的结果将是 通过在全国范围内进行的随机人工病历审查确定的检测结果缺失率 作为VHA性能测量系统的一部分，以及错过测试的自动“触发”指示器 结果我们假设在SAFER TRACKS期间参与研究中心遗漏的测试结果会更少 干预期间与干预前期间相比。 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， 确定参与研究中心的优势和挑战。 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、减轻和 改善基于EHR的通信故障，这些故障经常导致VHA中的测试结果丢失。 意义：该项目是响应“有针对性的征求卫生服务研究的数据和 测量科学-一个学习型医疗保健系统倡议”和HSR&D的主要优先领域， 医疗保健信息学和子领域的创新使用信息技术，以改善诊断。

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.