Effectiveness of Electronic Health Record-Based Interventions for Improving Follow-Up in Primary Care
Condition: Colon Cancer; Lung Cancer; Prostate Cancer
MeSH terms: Colonic Neoplasms
Study type: Interventional

Summary: 
      Diagnostic delays in ambulatory care are often due to breakdowns of related care processes.
      Electronic systems can improve follow-up and reduce delays by detecting missed appointments
      or incomplete procedures so that patients are called back to conduct timely investigations
      when appropriate. To achieve high standards of patient safety in cancer diagnosis, the
      investigators not only need to use information technology appropriately but also improve the
      processes, policies, and procedures of monitoring, communication, and coordination of care.

      Given the importance of cancer-related diagnostic delays in ambulatory care, the
      investigators need effective methods to detect them, understand their causes, and intervene
      to reduce them. Manual techniques to detect these delays, such as spontaneous reporting and
      random chart reviews, have limited effectiveness. Our proposed study focuses on testing
      methods to proactively identify delays using certain "triggers" as they occur and intervene
      in a timely manner.
    

Detailed description: 
      The goal of this proposal is to demonstrate and test methods by which large health care
      systems can efficiently identify cancer patients who are more likely to experience diagnostic
      delays and pre-emptively rectify these delays. This study will build upon tools developed in
      our recent work (Aim1, prior IRB Protocol Number: H-23801) and test their effectiveness to
      identify patients at risk of experiencing delays in cancer diagnosis followed by an
      intervention that the investigators hypothesize will reduce these delays.

      This is Aim 2 (for which the investigators are seeking approval) is the final Aim of this
      proposal. Aim 1 was approved under Protocol Number: H-23801.

      In Aim 2 the investigators will determine the effectiveness of an IT-based intervention
      (consisting of data mining using triggers tested in Aim 1 followed by targeted electronic
      communication and surveillance techniques) to facilitate cancer diagnosis as compared with
      usual care (no use of trigger or electronic communication and surveillance). Hypothesis 1:
      The time from first appearance of a diagnostic clue to follow-up action (e.g. colonoscopy
      performance after a positive FOBT) will be significantly less in the intervention arm than in
      usual care. Hypothesis 2: The percentage of patients receiving timely follow-up care will be
      significantly more in the intervention arm than in usual care. To improve the
      generalizability of our findings to multiple ambulatory care environments, the investigators
      will conduct our research in two settings: an urban Veterans Affairs facility in Houston,
      Texas and a large primary care network in central Texas. These settings include internal
      medicine and family medicine, academic and nonacademic practices, and significant racial,
      gender, ethnic, age, urban/rural, and socioeconomic diversity. Our study addresses
      coordination and timeliness of care, both of which are priorities to achieve high quality
      care.

      Hypothesis 3: Overall, the trigger will achieve a positive predictive value (PPV) of at least
      50% in identifying delays in care. PPV is defined as the number of charts correctly
      identified with a delay in diagnostic evaluation, divided by the total number of charts
      identified by the trigger, and was deemed to be the approximately level necessary to avoid
      substantial contribution to provider alert fatigue.
    

Intervention name(s): Contact Intervention
Intervention type(s): Behavioral
Intervention description(s): The intervention will include activities such as electronic communication and surveillance that facilitate the care of patients experiencing delays. A trained chart reviewer will conduct chart reviews on trigger-positive patients to confirm they are at risk for care delays and this will be followed by an electronic and/or verbal communication to the provider. The intervention will be compared to usual care at both sites.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Care Provider)
Primary purpose: Health Services Research
Keywords: Diagnostic delay; Prevention; Diagnostic errors