Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer (Texas)

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Summary:

Early diagnosis, management, and treatment of cancers confer improved survival, thus making timely diagnosis imperative. Delays in cancer diagnosis, however, are common and may arise when abnormal cancer screening results are missed by providers. These delays may result in a reduced opportunity for early and potentially curative cancer therapy.

This project used health information technology (IT) to identify patients for whom a diagnosis of prostate, lung, or colon cancer had been delayed, with the delay then communicated to providers. The specific aims of this project were to:

  • Identify patients with cancer-related diagnostic delays using trigger-based data mining of an electronic health record (EHR) repository.
  • Determine the effectiveness of a health IT-based intervention to facilitate cancer diagnosis as compared with usual care.

The project team developed electronic triggers to detect delays in diagnosis of the three cancers using information from literature reviews, expert opinion, and clinical logic. The triggers were then validated using manual chart reviews to determine the rate of a positive trigger in patients with cancer, i.e. the positive predictive value (PPV). Each of the triggers achieved PPVs of 58.3 to 70.2 percent. Based on this, use of the four triggers at the study sites could detect an estimated 1,048 instances of delayed or missed followup of abnormal findings and 47 high-grade cancers annually.

Using a randomized controlled trial design, the triggers were applied to all patients cared for by study providers over the course of 15 months. Manual chart reviews were conducted on records identified by the triggers to confirm and analyze the presence of diagnostic breakdowns. The patient’s treating provider was notified of the delay, and electronic tracking was used to monitor the patient. The study team compared the amount of time to followup action with the intervention versus the control patients.

Compared to the control group, patients cared for by providers in the intervention group experienced shorter time to followup care for the prostate and colorectal cancer triggers, while no difference was seen in the lung cancer triggers. Only 21 records with delayed followup were identified for lung cancer, and no difference in the time to follow up between intervention and control groups was observed.

Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017820
  • Project Period: 
    September 2008 – June 2013
  • AHRQ Funding Amount: 
    $1,199,531
  • PDF Version: 
    (PDF, 241.85 KB)

Summary: Patients with known or suspected cancers transition through several ambulatory care settings to receive timely diagnoses and treatment. The survival benefits conferred by early diagnosis and treatment depend on well-coordinated care. This project tests the use of health information technology (IT) to identify patients for whom the diagnosis of specific cancers (prostate, lung, or colon) might be delayed.

This project used data from two electronic health record (EHR) systems—the Veterans Administration’s (VA’s) Computerized Patient Record System and Veterans Health Information Systems and Technology Architecture (CPRS/VistA), and EMRx, the EHR at the Scott and White Health system, a large private integrated health care delivery system in central Texas—to develop, test, and refine queries to mine a clinical data warehouse for triggers that might signal a delayed diagnosis. A randomized controlled trial (RCT) was conducted, and providers in the intervention group received electronic communication and surveillance if potential delays in their patients’ diagnostic work-up were identified by the triggers. Outcome measures, obtained through chart reviews, consisted of time intervals between several key steps in the pathway of diagnosis.

Specific Aims:

  • Identify patients with cancer-related diagnostic delays using trigger-based data mining of an EHR repository. (Achieved)
  • Determine the effectiveness of a health IT-based intervention to facilitate cancer diagnosis as compared with usual care. (Achieved)

2012 Activities: The focus of 2012 was the completion of the RCT in July to test the intervention of delivering information to primary care providers about their “trigger-positive” patients, i.e., patients with potential delays in the diagnostic evaluation for colorectal, lung, or prostate cancer. Seventy-two providers were recruited. The second half of the year was dedicated to chart reviews from the intervention and control group medical records. A preliminary statistical analysis of the effectiveness of the triggers and the intervention on improving diagnosis and followup has been completed, and further in-depth analysis of the data was ongoing at the end of the year.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track, and project budget spending is on target. Due to initial project delays and the unanticipated amount of time needed to develop the initial triggers, the project team used two no-cost extensions to complete the RCT, chart reviews, and the subsequent analysis.

Preliminary Impact and Findings: Preliminary analysis of the trigger algorithm revealed that patients under the care of an intervention group provider were more likely to receive subsequent appropriate followup action for colorectal and prostate cancer, indicating that employing an electronic trigger-based program to identify patients with potential delays in cancer-related care, and using these findings to inform the respective provider of confirmed delays in diagnosis can mitigate delays in cancer diagnosis and care.

Target Population: Adults, Cancer: Colon, Lung, and Prostate, Veterans

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017820
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,199,531
  • PDF Version: 
    (PDF, 181.05 KB)

Summary: Patients with known or suspected cancers transition through several ambulatory care settings to receive timely diagnosis and treatment. The survival benefits conferred by early diagnosis and treatment depend on well-coordinated care. This project tests the use of health information technology (IT) to identify patients for whom the diagnosis of specific cancers (prostate, lung, or colon) has been delayed.

This project is using data from two electronic health record (EHR) systems (the Veterans Administration's [VA's] Computerized Patient Record System and Veterans Health Information Systems and Technology Architecture, and EMRx, the EHR at the Scott and White Health system, a large private integrated health care delivery system in central Texas) to develop, test, and refine queries to mine a clinical data warehouse for triggers that might signal diagnosis delays. Providers in the intervention group of the randomized controlled trial (RCT) receive electronic communication and surveillance if potential delays in their patients' diagnostic work-up are identified by the triggers. Outcome measures, obtained through chart reviews, consist of time intervals between several key steps in the optimal pathway of diagnosis.

Specific Aims:

  • Identify patients with cancer-related diagnostic delays using trigger-based data mining of an EHR repository. (Ongoing)
  • Determine the effectiveness of a health IT-based intervention to facilitate cancer diagnosis as compared with usual care. (Ongoing)

2011 Activities: During 2011, Dr. Singh and his team continued to develop cancer triggers based on the colorectal cancer triggers they developed in 2010. By the end of 2011, the colorectal and prostate cancer triggers were developed, and the data collection, validation, and analysis of the triggers for identifying patients with cancer-related diagnostic delays were complete at both the VA and non-VA site. An abstract based on preliminary findings of the colon and prostate cancer triggers at the VA site was presented at the 2011 VA Health Services Research and Development Service Annual Meeting in Washington, D.C. in February 2011, and at the Society of General Internal Medicine 34th Annual Meeting in Phoenix, Arizona in May 2011. The team also completed a manuscript describing the results of both the colorectal and prostate EHR triggers to detect delays in cancer diagnosis. This manuscript is under review for publication.

Each trigger required mining more than 200,000 medical records. A team comprised of clinical providers and a programmer met weekly to define the appropriate clinical criteria and determine how to implement them, taking into account the limitations of the health information systems at the sites. Each trigger is composed of several clinical rules (e.g. criteria). Each rule required multiple record review sessions, during which providers tested the triggers by identifying the documented clinical evidence that supported or contradicted the triggers' rules. Validation included a medical chart review to determine whether the identified patients were truly at risk for delayed cancer diagnosis.

The RCT is underway to test the intervention of delivering information about trigger-identified potential delays in the care of colorectal or prostate cancer to their respective primary care providers. The intervention consisted of data mining to facilitate cancer diagnosis using triggers developed for the first aim, followed by targeted electronic communication and surveillance, as compared with usual care. Recruitment for the RCT began in March 2011 and has been completed at both the VA and non-VA sites. Sixty-three providers have consented to participate in the study, and demographics have been collected from each provider via an electronic survey. A total of 25 rounds of data have been extracted for 13 months, and intervention group providers are being contacted for positive triggers. A preliminary analysis of the data collected thus far is underway.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and project budget spending is on target. Due to initial project delays in 2009 and the unanticipated amount of time needed to develop the initial triggers, the project team is using a 1-year no-cost extension to ensure adequate time for the RCT and subsequent analysis and manuscript preparation.

Preliminary Impact and Findings: A total of 292,587 and 291,773 patient records were evaluated by the triggers for prostate and colorectal cancer, respectively. Overall, the triggers identified 1,564 patients with potential delays in care (426 for prostate and 1,138 for colorectal cancer triggers). Chart reviews performed on all 426 prostate and 258 randomly-selected colorectal cancer trigger-positive records revealed that 299 (70.2 percent) and 166 (64.3 percent) were correctly identified as having delayed care. Additionally, reviews identified that 11.6 percent of patients with delayed care were subsequently diagnosed with cancerous or precancerous lesions.

Target Population: Adults, Cancer: Colon, Lung, and Prostate, Veterans

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017820
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,199,531
  • PDF Version: 
    (PDF, 289.64 KB)


Target Population: Adults, Cancer: Colon, Lung, and Prostate, Veterans

Summary: Patients with known or suspected cancers transition through several ambulatory care settings to receive timely diagnosis and treatment. The survival benefit conferred by early diagnosis and treatment depends on well-coordinated care. This project tests the use of health information technology (IT) to identify patients where the diagnosis of specific cancers (prostate, lung, and colon) has been delayed. The project develops, tests, and refines queries to mine a clinical data warehouse for triggers that might signal diagnosis delays using data from the Veterans Administration’s (VA’s) electronic health record (EHR), the Computerized Patient Record System (CPRS) and Veterans Health Information Systems and Technology Architecture (VistA); and EMRx, the Scott and White Health system’s EHR. Providers in the intervention group of the upcoming randomized, controlled trial (RCT) will receive electronic communication and surveillance if potential delays in their patients’ diagnostic work-up are identified by the triggers. Outcome measures, obtained through chart reviews, consist of time intervals between several key steps in the optimal pathway of diagnosis.

Specific Aims:
  • Identify patients with cancer-related diagnostic delays using trigger-based data mining of an EHR repository. (Ongoing)
  • Determine the effectiveness of a health IT-based intervention to facilitate cancer diagnosis as compared with usual care. (Upcoming)

2010 Activities: During 2010, Dr. Singh and his team finalized the development of the colon cancer triggers. This process included a medical chart review of 180 charts at both the VA and non-VA sites to validate the triggers to determine whether the identified patients were truly at risk for delayed colon cancer diagnosis. Analysis of the data is ongoing and the preliminary results have been accepted as an oral presentation at the 2011 VA Health Services Research and Development Service Annual Meeting in Washington, D.C.

The team also applied the framework for developing colon cancer triggers to create triggers to identify those at risk for delayed lung and prostate cancer diagnosis. The framework is comprised of three steps to guide the design and development of electronic triggers that identify potential and actual delays in diagnosis using data from integrated EHRs. The framework involves: mapping all followup events expected to occur in response to a particular diagnostic clue; verifying the trigger’s logic as it is developed (e.g. anemia not followed by colonoscopy in a defined time period); and providing continuous and iterative feedback to improve the trigger.

Each trigger required mining more than 200,000 medical records over a 6-month period. A team composed of clinical providers and a programmer met weekly to define the appropriate clinical criteria and determine how to best implement them, taking into account the limitations of the health information systems at the sites. Each trigger is composed of several clinical rules (e.g. criteria). Each rule required multiple record review sessions, during which providers tested the triggers by identifying the documented clinical evidence that supported or contradicted the triggers’ rules.

By the end of 2010, the triggers for prostrate cancer were developed; validation at both the VA and non-VA sites is underway. The development of the lung cancer triggers are close to completion and data validation will start in early 2011. In parallel, the team is awaiting final Institutional Review Board approval at both sites for testing the interventions in a RCT, scheduled to begin in March 2011.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is on track in some respects, but not others and budgeted funds are somewhat underspent. The initial deadline was not met due to delays in 2009. This included the announcement of a new national VA policy on developing data repositories for research purposes which delayed the creation of the data warehouse for this project at the VA. In addition, the development of the colon cancer trigger took more time than anticipated. However, the experience and knowledge gained informed and expedited the development of the triggers for prostate and lung in 2010 and the team does not anticipate any other significant delays.

Preliminary Impact and Findings: Dr. Singh and his team conducted a pilot to test the colon cancer triggers and assess if the patients identified were truly at risk. They found that of the 89,187 patients to whom the trigger was applied, 595 patients were identified as at risk. Of the 120 patient charts reviewed, 90 (75 percent) were true trigger positives. This observation indicates EHR-based trigger methods are potentially useful to detect potential delays in colorectal cancer diagnosis.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - Final Report

Citation:
Singh H. Using Electronic Data to Improve Care of Patients With Known or Suspected Cancer - Final Report. (Prepared by Baylor College of Medicine under Grant No. R18 HS017820). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 139 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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