Ambulatory Safety Nets: Creating High-Reliability Solutions to Prevent

Ambulatory Safety Nets: Creating High-Reliability Solutions to Prevent Missed and Delayed Diagnoses Sonali Desai, MD, MPH April 3, 2019 Reliable systems are needed for abnormal test result follow-up Alleviation of clinician burnout Collaboration with existing programs

Interventions with high-impact potential Leveraging technology High-risk areas What are the key ingredients for a safety net? Patient registries Workflow redesign Patient outreach and

tracking Colon Cancer Safety Nets Identify patients at risk for delayed diagnosis of colon cancer Leverage Epic Safety Net registries of patients with prior colonoscopy with pathology, iron deficiency anemia or rectal bleeding Conduct population-based outreach to promote colonoscopy

Patients with prior colonoscopy/ pathology due to return At-risk for colon cancer Rectal bleeding

Irondeficiency anemia Lung Cancer Safety Net Nodules from 2016-2017 NLP on radiology reports to identify nodules Chart review validation for true

incidental nodules requiring f/u Nodules in 2018 Deploy a more automated lung nodule communication, scheduling and tracking system in collaboration with Radiology (RADAR) Email PCPs with lists and track patient f/u Primary

Care at BWH Incidental Lung Nodules ED, Inpatient Followed at BWH by Specialist Basics of Building a Safety Net Program

Step 1: Build Patient Registry Requires effort to ensure clinician proactively enters Data elements Coded data Registry

NLP Requires effort to extract and validate with chart review Step 2: Clinical Best Practice Guideline Development How many at-risk patients are identified?

What do external guidelines say? Pri Care GI Is there local agreement with guidelines?

Radiology Clinical pathways to pilot within practices or departments What is unique to your patient population or org structure and feasible? Level of Evidence matters expert opinion valid guideline

that clinicians are willing to follow Step 3: Workflow Redesign Step 4: Patient Outreach and Tracking What is the right team composition? Centralized, de-centralized or hybrid process? Outreach via phone, letter,

text or in-person? Colon Cancer Safety Nets Colon Cancer Safety Nets GI Recall Registry: Abnormal Colonoscopy (Cscope) + Pathology How does one identify the patient as being due for their next c-scope? C-scope

done years ago C-scope result Pathology Patient risk factors Shared responsibility for the patients followup care plan between GI and Primary Care by shifting responsibility of updating return

interval in EMR Return interval for next cscope Patient Navigator Transportation Do you have someone who can pick you up after the procedure? We provide transportation and escort services within the Boston-Metro area

Colonoscopy Prep Would it be helpful if I walked through the prep instructions with you? Do you need reminder calls during your preparation? Letter phone call letter format works the best for outreaching to patients Interpreter

(If necessary) would an interpreter be helpful? We can send you prep instructions in English or Spanish Clinical Vignette 28 year old female with IBD had last colonoscopy in 2015 Identified through Safety Net registry as due for colonoscopy in January 2018 2 letters sent to patient using registry functionality Patient scheduled for colonoscopy April 2018 Colonoscopy identified high-grade dysplasia Surgical consultation obtained with recommendation for colectomy to prevent future colon cancer

Even one early detection can demonstrate the immediate impact of Safety Nets on patient care Rectal Bleeding (RB) and Iron-Deficiency Anemia (IDA) Safety Nets Rectal Bleeding and Iron-Deficiency Anemia Pilot program with 4 Primary Care Practices started July 2018 Lesson learned: electronic registries need to be more specific and actionable to minimize chart review burden (over 3,500 patients identified as at-risk) Cumulative Practice Totals

N = 312 Excluded after 21.15% 2.24% 2.56% 58.65% 15.38% chart review Brought before the provider Pending outreach

C-Scope scheduled C-Scope completed Clinical Vignette PHM did chart review on patient with RB Noted that patient has Ulcerative Colitis and is followed by BWH GI but c-scope not done, just sigmoidoscopy PHM coordinated communication b/w GI MD, PCP and GI triage RN plan made for discussion with patient on importance of cscope PHM talked to patient and scheduled c-scope for November 2018 Early findings from RB/ IDA work suggest that even patients with multiple BWH physicians may fall through the cracks without

adequate patient outreach, coordination of care, education and navigation Cumulative Impact of Colon Cancer Safety Net: GI Recall and RB/ IDA work Lung Cancer Safety Net Lung Nodule Safety Nets: 2016-2017 Apply NLP to radiology reports Cross reference

with BWH PCP, DFCI, Thoracic Surgery Identify Narrow scope Patient outreach and track

Validate Email PCPs with lists and track if f/u completed Chart review to ensure true incidental nodule Lung Cancer Safety Net: RADAR 2018 Radiology

Result Alert & Acknowledge Develop a Follow-up Plan Resolution Automated

March 2018 pilot in Primary Care practices Radiology will send you an alert, suggest specific follow-up, offer to schedule the test and alert you if not completed in recommended timeframe RADAR: What the Ordering Clinician Sees Radiology system with automatically check to see if

follow-up chest CT scan is completed in recommended timeframe if not, it will then send alert to Radiology and PCP (or ordering clinician) Closed-Loop Follow-Up American Journal of Radiology, May 2019 (in-press)

RADAR Adoption: March August 2018 RADAR: Speed and Likelihood of Scheduling Usual Alert Success Rate = 25% 13 Days Time to Scheduling 21.3 39

Scheduled Not Scheduled RADAR Success Rate = 80% 7 Blue->Yellow 2 Blue Alert Type RADAR Alerts are scheduled faster than usual notification alerts

28 Scheduled Not Scheduled RADAR alerts are more likely to be scheduled than usual alerts use of Radiology central scheduling Lung Nodule Next Steps Pri Care

March 2018 Pulmonar y Jan 2019 Medicine Specialties Feb 2019 Inpatient and ED 2019

Ambulatory Safety Nets: Beyond Colon and Lung Cancer Radiology Cancer Medicatio n Safety Breast (BIRADS3) Prostate

High-risk medications Pancreatic cysts Cervical High-risk patients Patient

Navigator #1 Patient Navigator #2 Project Manager Pharmacist Medical Director

New Ambulatory Safety Net team funded through hospital operating budget for 2019 to maintain, scale and develop new Safety Nets Challenges and Opportunities Data, Registries, and Reporting Patient Outreach, Tracking and Communication

Ambulatory Patient Safety as Hospital Priority Questions? Sonali Desai: [email protected] du

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