Follow-up on Abnormal Cancer Screenings:

Creating a system-wide, EMR-based solution to improve patient safety and reduce medical errors

Cambridge Health AllianceDavid Osler, MD MPH

Louise Weed, MS

The Problem“Achieving a model patient safety profile: An Ambulatory RAP (Risk Appraisal Plan) for

Cambridge Health Alliance.” Presented by CRICO to CHA in 2011

• CHA’s average test results management score from CRICO’s Office Practice Evaluations: 72%

• Of all malpractice claims 2005-2009, contributing factors included:

– Communication in 42% of cases

– Clinical systems in 37% of cases

• Staff overworking with ineffective systems

The GoalEnsure that 100% of our patients with abnormal results are

aware, have appropriate documentation, and a follow-up plan

Patient Lab Test

Individual Result for Patient

Auto-populated EPIC list

Patient NotifiedOr

Appropriate notification attempt

Appropriate documentation in

EMR

Assigned nursing staff use lists to validate

appropriate steps have been taken & documented

List is audited quarterly

Provider

Provider

Provider

Follow-up plan created and

started

Closing the loop on referrals

The Method• Create an automated, system-wide safety net for all

patients with abnormal cancer screenings– Automated patient lists embedded in our EMR

(Epic)– Audit checklists built into EMR – Automated removal of patients based on checklist

• Find/ create the data:– Pap, PSA, Mammogram– Partnership with appropriate departments

• Build patient lists and audit tools– Consensus on “follow-up”, integration with other

safety tools

OutcomesPilot in three Primary Care health centers

• Percentage with all steps completed – Patients whose records needed updating– Near-misses

• Assessment reports

• Nursing and Provider satisfaction

• Change in start date

Challenges, Lessons Learned• It takes a village (and then some)!

– Perseverance and partnership

• Workflow expectations and reality– Ongoing trust issues with automation– Expectations between Nurses and Providers– Changes in screening and f/u guidelines– Who “owns” the patient – PCP vs. Specialist– Definition of abnormal

• Accountability & Communication• Pros and Cons of IT based systems• No system is perfect