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IIR 17-127 – HSR Study

IIR 17-127
Measuring and Improving the Safety of Test Result Follow-Up
Hardeep Singh, MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: October 2018 - September 2023


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.

External Links for this Project

NIH Reporter

Grant Number: I01HX002439-01A1

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Journal Articles

  1. Meyer AND, Scott TMT, Singh H. Adherence to National Guidelines for Timeliness of Test Results Communication to Patients in the Veterans Affairs Health Care System. JAMA Network Open. 2022 Apr 1; 5(4):e228568. [view]
  2. Murphy DR, Kadiyala H, Wei L, Singh H. An electronic trigger to detect telemedicine-related diagnostic errors. Journal of telemedicine and telecare. 2024 Apr 1; 1357633X241236570. [view]
  3. Murphy DR, Giardina TD, Satterly T, Sittig DF, Singh H. An Exploration of Barriers, Facilitators, and Suggestions for Improving Electronic Health Record Inbox-Related Usability: A Qualitative Analysis. JAMA Network Open. 2019 Oct 2; 2(10):e1912638. [view]
  4. Sittig DF, Lakhani P, Singh H. Applying requisite imagination to safeguard electronic health record transitions. Journal of the American Medical Informatics Association : JAMIA. 2022 Apr 13; 29(5):1014-1018. [view]
  5. Bradford A, Singh H. Building clinical pathways of the future that improve safety and reduce waste in healthcare. Journal of hospital medicine. 2023 Feb 1; 18(2):200-201. [view]
  6. Murphy DR, Savoy A, Satterly T, Sittig DF, Singh H. Dashboards for visual display of patient safety data: a systematic review. BMJ health & care informatics. 2021 Oct 1; 28(1). [view]
  7. Giardina TD, Hunte H, Hill MA, Heimlich SL, Singh H, Smith KM. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies' Report Improving Diagnosis in Health Care. Journal of Patient Safety. 2022 Dec 1; 18(8):770-778. [view]
  8. Kapadia P, Zimolzak AJ, Upadhyay DK, Korukonda S, Murugaesh Rekha R, Mushtaq U, Mir U, Murphy DR, Offner A, Abel GA, Lyratzopoulos G, Mounce LTA, Singh H. Development and Implementation of a Digital Quality Measure of Emergency Cancer Diagnosis. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2024 May 8; JCO2301523. [view]
  9. Bradford A, Shahid U, Schiff GD, Graber ML, Marinez A, DiStabile P, Timashenka A, Jalal H, Brady PJ, Singh H. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events. Journal of Patient Safety. 2022 Sep 1; 18(6):521-525. [view]
  10. Bradford A, Meyer AND, Khan S, Giardina TD, Singh H. Diagnostic error in mental health: a review. BMJ quality & safety. 2024 Apr 15. [view]
  11. Walter FM, Thompson MJ, Wellwood I, Abel GA, Hamilton W, Johnson M, Lyratzopoulos G, Messenger MP, Neal RD, Rubin G, Singh H, Spencer A, Sutton S, Vedsted P, Emery JD. Evaluating diagnostic strategies for early detection of cancer: the CanTest framework. BMC cancer. 2019 Jun 14; 19(1):586. [view]
  12. Singh H, Connor DM, Dhaliwal G. Five strategies for clinicians to advance diagnostic excellence. BMJ (Clinical research ed.). 2022 Feb 16; 376:e068044. [view]
  13. Shafer GJ, Singh H, Thomas EJ, Thammasitboon S, Gautham KS. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. Journal of perinatology : official journal of the California Perinatal Association. 2022 Oct 1; 42(10):1312-1318. [view]
  14. Sittig DF, Sengstack P, Singh H. Guidelines for US Hospitals and Clinicians on Assessment of Electronic Health Record Safety Using SAFER Guides. JAMA. 2022 Feb 22; 327(8):719-720. [view]
  15. Shen L, Levie A, Singh H, Murray K, Desai S. Harnessing Event Report Data to Identify Diagnostic Error During the COVID-19 Pandemic. Joint Commission Journal on Quality and Patient Safety. 2022 Feb 1; 48(2):71-80. [view]
  16. Giardina TD, Royse KE, Khanna A, Haskell H, Hallisy J, Southwick F, Singh H. Health Care Provider Factors Associated with Patient-Reported Adverse Events and Harm. Joint Commission Journal on Quality and Patient Safety. 2020 May 1; 46(5):282-290. [view]
  17. Zhou Y, Walter FM, Mounce L, Abel GA, Singh H, Hamilton W, Stewart GD, Lyratzopoulos G. Identifying opportunities for timely diagnosis of bladder and renal cancer via abnormal blood tests: a longitudinal linked data study. The British journal of general practice : the journal of the Royal College of General Practitioners. 2022 Jan 1; 72(714):e19-e25. [view]
  18. Ramesh S, Ayres B, Eyck PT, Dawson JD, Reisinger HS, Singh H, Herwaldt LA, Cifra CL. Impact of subspecialty consultations on diagnosis in the pediatric intensive care unit. Diagnosis (Berlin, Germany). 2022 Aug 1; 9(3):379-384. [view]
  19. Thirnbeck CK, Espinoza ET, Beaman EA, Rozen AL, Dukes KC, Singh H, Herwaldt LA, Landrigan CP, Reisinger HS, Cifra CL. Interfacility Referral Communication for PICU Transfer. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2024 Jun 1; 25(6):499-511. [view]
  20. Giardina TD, Choi DT, Upadhyay DK, Korukonda S, Scott TM, Spitzmueller C, Schuerch C, Torretti D, Singh H. Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. Journal of the American Medical Informatics Association : JAMIA. 2022 May 11; 29(6):1091-1100. [view]
  21. Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic errors. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2022 Sep 10; 34(3). [view]
  22. Rajan SS, Sarvepalli S, Wei L, Meyer AND, Murphy DR, Choi DT, Singh H. Medical Home Implementation and Follow-Up of Cancer-Related Abnormal Test Results in the Veterans Health Administration. JAMA Network Open. 2024 Mar 4; 7(3):e240087. [view]
  23. Makris KI, Clark DL, Buffie AW, Steen EH, Ramsey DJ, Singh H. Missed Opportunities to Promptly Diagnose and Treat Adrenal Tumors. The Journal of surgical research. 2022 Aug 1; 276:174-181. [view]
  24. Meyer AND, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: Current understanding and future directions. Patient education and counseling. 2021 Nov 1; 104(11):2606-2615. [view]
  25. Sittig DF, Singh H. Policies to Promote Shared Responsibility for Safer Electronic Health Records. JAMA. 2021 Oct 19; 326(15):1477-1478. [view]
  26. Fischer H, Hahn EE, Li BH, Munoz-Plaza CE, Luong TQ, Harrison TN, Slezak JM, Sim JJ, Mittman BS, Lee EA, Singh H, Kanter MH, Reynolds K, Danforth KN. Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure. Joint Commission Journal on Quality and Patient Safety. 2022 Apr 1; 48(4):222-232. [view]
  27. Gandhi TK, Singh H. Reducing the Risk of Diagnostic Error in the COVID-19 Era. Journal of hospital medicine. 2020 Jun 1; 15(6):363-366. [view]
  28. Cifra CL, Dukes KC, Ayres BS, Calomino KA, Herwaldt LA, Singh H, Reisinger HS. Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography. Journal of Critical Care. 2021 Jun 1; 63:246-249. [view]
  29. Cifra CL, Tigges CR, Miller SL, Curl N, Monson CD, Dukes KC, Reisinger HS, Pennathur PR, Sittig DF, Singh H. Reporting Outcomes of Pediatric Intensive Care Unit Patients to Referring Physicians via an Electronic Health Record-Based Feedback System. Applied clinical informatics. 2022 Mar 1; 13(2):495-503. [view]
  30. Read AJ, Waljee AK, Sussman JB, Singh H, Chen GY, Vijan S, Saini SD. Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians. JAMA Network Open. 2021 Oct 1; 4(10):e2127827. [view]
  31. Vaghani V, Wei L, Mushtaq U, Sittig DF, Bradford A, Singh H. Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments. Journal of the American Medical Informatics Association : JAMIA. 2021 Sep 18; 28(10):2202-2211. [view]
  32. Zimolzak AJ, Shahid U, Giardina TD, Memon SA, Mushtaq U, Zubkoff L, Murphy DR, Bradford A, Singh H. Why Test Results Are Still Getting "Lost" to Follow-up: a Qualitative Study of Implementation Gaps. Journal of general internal medicine. 2022 Jan 1; 37(1):137-144. [view]

DRA: Cancer
DRE: Technology Development and Assessment, Treatment - Implementation, TRL - Applied/Translational
Keywords: Best Practices, Care Management Tools, Electronic Health Record, Guideline Development and Implementation, Surveillance
MeSH Terms: None at this time.

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