For this post, we asked one of our Department of Quality and Safety medical directors, Sonali Desai, MD, MPH to discuss a safety improvement initiative related to patient diagnoses of cancer.
We have all been susceptible to the effects of multi-tasking: you unlock your smartphone to call someone, but are interrupted by an incoming text message, followed by an email from your supervisor. Before you know it, you have forgotten what you were doing with your phone in the first place. Health care is no different — the rapid pace of delivering care in the ambulatory setting, coupled with the wealth of data to process complex medical decisions, poses a similar multi-tasking risk to busy clinicians. What often keeps clinicians up at night is worrying about missing a diagnosis of cancer due to not following up on an abnormal test result.
You may wonder, how could this happen? Imagine that you undergo a CT scan of your chest for shortness of breath — although a serious diagnosis such as a blood clot or lung cancer is not found during the exam, a small incidental lung nodule is discovered. The nodule may or may not lead to cancer, but it often requires a follow-up CT scan in several months, or up to one year.
Or, consider a colonoscopy to screen for colon cancer that detects a few polyps. These polyps are not cancerous but they warrant another colonoscopy be performed in a few years. The issue with these follow-up exams is that physicians’ offices often do not have reliable recall systems to ensure that all patients with incidental lung nodules or abnormal polyps return for the repeat testing they need months or years from when the first test was done – this is how something can fall through the cracks.
Recently at Brigham Health, we piloted the concept of Ambulatory Safety Nets to help catch potential findings that could lead to cancer diagnoses, modeled after work done through the Kaiser Permanente SureNet programs.1 Ambulatory Safety Nets provide a way to help offload the cognitive burden on busy clinicians by creating a team that can help to centrally identify, coordinate, contact and track patients who need follow-up tests. At the Brigham, this project is being piloted for colon and lung cancer screenings. Ambulatory Safety Nets take a more proactive and centralized approach that can leverage technology to work closely with primary care practices. In our early efforts for the colon cancer safety net, we have been able to complete over 200 colonoscopies for patients at-risk for colon cancer based on abnormal prior colonoscopies and symptoms such as rectal bleeding and iron deficiency anemia. To date, we have identified at least one patient with a high-risk precancerous finding requiring surgery and several patients with polyps.
For our lung cancer safety net, we have found over 300 patients with incidental lung nodules using artificial intelligence on radiology reports. We have developed follow-up care plans with primary care and radiology for determining whether patients need further imaging or referral. We have launched a new program, Radiology Result Alert and Acknowledge for Development of Automated Resolution (RADAR), which leverages a web-based radiology result notification system to create collaborative care plans between radiologists and ordering clinicians, assists with scheduling and patient outreach of follow-up imaging, and tracks whether appropriate care has been delivered to patients.2
Reducing the burden on our physicians and developing an engaged team has provided the opportunity to raise the standard of care that we provide to our patients. We are working on expanding our pilot to encompass more preventive opportunities in breast, cervical and prostate cancer and to design safety nets for ambulatory medication errors and diagnostic errors.
1 Emani S, Sequist TD, Lacson R, Khorasani R, Jajoo K, Holtz L, Desai S. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer. Jt Comm J Qual Patient Saf. 2019 Jul 05. PMID: 31285149
2 Hammer MM, Kapoor N, Desai SP, Sivashanker KS, Lacson R, Demers JP, Khorasani R. Adoption of a Closed-Loop Communication Tool to Establish and Execute a Collaborative Follow-Up Plan for Incidental Pulmonary Nodules. AJR Am J Roentgenol. 2019 Feb 19; 1-5. PMID: 30779667