Appl Clin Inform 2017; 08(01): 279-290
DOI: 10.4338/ACI-2016-10-RA-0176
Research Article
Schattauer GmbH

Application of Electronic Algorithms to Improve Diagnostic Evaluation for Bladder Cancer[*]

Daniel R. Murphy
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
2   Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
,
Ashley N.D. Meyer
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
2   Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
,
Viralkumar Vaghani
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
2   Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
,
Elise Russo
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
2   Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
,
Dean F. Sittig
3   University of Texas Health Science Center at Houston’s School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
,
Kyle A. Richards
4   Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
,
Li Wei
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
2   Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
,
Louis Wu
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
,
Hardeep Singh
1   Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
2   Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
› Institutsangaben
Funding This project is funded by a Veteran Affairs Health Services Research and Development CREATE grant (CRE-12-033) and partially funded by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). Dr. Murphy is additionally funded by an Agency for Healthcare Research & Quality Mentored Career Development Award (K08-HS022901) and Dr. Singh is additionally supported by the VA Health Services Research and Development Service (CRE 12-033; Presidential Early Career Award for Scientists and Engineers USA 14-274), the VA National Center for Patient Safety and the Agency for Health Care Research and Quality (R01HS022087). These funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Weitere Informationen

Correspondence to:

Daniel R Murphy, MD MBA
Michael E DeBakey Veterans Affairs Medical Center (MEDVAMC)
Houston Center for Innovations in Quality, Effectiveness & Safety (IQuESt) (152)
2002 Holcombe Boulevard
Houston, TX
77030 USA 713-440–4600 (o), 713-748–7359 (f)

Publikationsverlauf

Received: 20. Oktober 2016

Accepted: 13. Januar 2017

Publikationsdatum:
20. Dezember 2017 (online)

 

Summary

Background: Strategies to ensure timely diagnostic evaluation of hematuria are needed to reduce delays in bladder cancer diagnosis.

Objective: To evaluate the performance of electronic trigger algorithms to detect delays in hematuria follow-up.

Methods: We developed a computerized trigger to detect delayed follow-up action on a urinalysis result with high-grade hematuria (>50 red blood cells/high powered field). The trigger scanned clinical data within a Department of Veterans Affairs (VA) national data repository to identify all patient records with hematuria, then excluded those where follow-up was unnecessary (e.g., terminal illness) or where typical follow-up action was detected (e.g., cystoscopy). We manually reviewed a randomly-selected sample of flagged records to confirm delays. We performed a similar analysis of records with hematuria that were marked as not delayed (non-triggered). We used review findings to calculate trigger performance.

Results: Of 310,331 patients seen between 1/1/2012-12/31/2014, the trigger identified 5,857 patients who experienced high-grade hematuria, of which 495 experienced a delay. On manual review of 400 randomly-selected triggered records and 100 non-triggered records, the trigger achieved positive and negative predictive values of 58% and 97%, respectively.

Conclusions: Triggers offer a promising method to detect delays in care of patients with high-grade hematuria and warrant further evaluation in clinical practice as a means to reduce delays in bladder cancer diagnosis.


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Conflicts of interest

The authors declare that they have no conflicts of interest in the research.

* The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.


  • References

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  • 2 Hollenbeck BK, Dunn RL, Ye Z, Hollingsworth JM, Skolarus TA, Kim SP, Montie JE, Lee CT, Wood DP, Miller DC. Delays in diagnosis and bladder cancer mortality. Cancer 2010; 116 (Suppl. 22) 5235-5242.
  • 3 Mahmud SM, Fong B, Fahmy N, Tanguay S, Aprikian AG. Effect of Preoperative Delay on Survival in Patients With Bladder Cancer Undergoing Cystectomy in Quebec: A Population Based Study. J Urol 2006; 175 (Suppl. 01) 78-83.
  • 4 Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, Macleod U, Mitchell ED, Pickett M, Rai T, Shaw K, Stuart N, Tørring ML, Wilkinson C, Williams B, Williams N, Emery J. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer 2015; 112 s1 S92-S107.
  • 5 Bergman J, Neuhausen K, Chamie K, Scales CD, Carter S, Kwan L, Lerman SE, Aronson W, Litwin MS. Building a Medical Neighborhood in the Safety Net: An Innovative Technology Improves Hematuria Workups. Urology 2013; 82 (Suppl. 06) 1277-1282.
  • 6 Lyratzopoulos G, Neal RD, Barbiere JM, Rubin GP, Abel GA. Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol 2012; 13 (Suppl. 04) 353-365.
  • 7 Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP. Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey. BMJ Open 2013; 3 (Suppl. 06) e002861.
  • 8 Dobruch J, Daneshmand S, Fisch M, Lotan Y, Noon AP, Resnick MJ, Shariat SF, Zlotta AR, Boorjian SA. Gender and Bladder Cancer: A Collaborative Review of Etiology, Biology, and Outcomes. Eur Urol 2016; 69 (Suppl. 02) 300-310.
  • 9 Cohn JA, Vekhter B, Lyttle C, Steinberg GD, Large MC. Sex disparities in diagnosis of bladder cancer after initial presentation with hematuria: a nationwide claims-based investigation. Cancer 2014; 120 (Suppl. 04) 555-561.
  • 10 Nieder AM, Lotan Y, Nuss GR, Langston JP, Vyas S, Manoharan M, Soloway MS. Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urol Oncol Semin Orig Investig 2010; 28 (Suppl. 05) 500-503.
  • 11 Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, Messing EM, Miller SD, Peterson AC, Turk TMT, Weitzel W. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 2012; 188 s6 2473-2481.
  • 12 Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010; 19 s3 i68-i74.
  • 13 Lyratzopoulos G, Vedsted P, Singh H. Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation. Br J Cancer 2015; 112 s1 S84-S91.
  • 14 Tarkan S, Plaisant C, Shneiderman B, Hettinger AZ. Reducing Missed Laboratory Results: Defining Temporal Responsibility, Generating User Interfaces for Test Process Tracking, and Retrospective Analyses to Identify Problems. AMIA Annu Symp Proc 2011; 1382-1391.
  • 15 Månsson Å, Anderson H, Colleen S. Time Lag to Diagnosis of Bladder Cancer–Influence of Psychosocial Parameters and Level of Health-Care Provision. Scand J Urol Nephrol 1993; 27 (Suppl. 03) 363-369.
  • 16 Chen EH, Bodenheimer T. Improving Population Health Through Team-Based Panel Management: Comment on “Electronic Medical Record Reminders and Panel Management to Improve Primary Care of Elderly Patients.”. Arch Intern Med 2011; 171 (Suppl. 17) 1558-1559.
  • 17 Murphy DR, Reis B, Kadiyala H, Hirani K, Sittig DF, Khan MM, Singh H. Electronic Health Record-Based Messages to Primary Care Providers: Valuable Information or Just Noise?. Arch Intern Med 2012; 172 (Suppl. 03) 283.
  • 18 Murphy DR, Reis B, Sittig DF, Singh H. Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med 2012; 125 (Suppl. 02) 209. e1-7.
  • 19 Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Smith MW, Murphy DR, Espadas D, Laxmisan A, Sittig DF. Primary care practitioners’ views on test result management in EHR-enabled health systems: a national survey. J Am Med Inform Assoc 2013; 20 (Suppl. 04) 727-735.
  • 20 Smith M, Murphy D, Laxmisan A, Sittig D, Reis B, Esquivel A, Singh H. Developing Software to “Track and Catch” Missed Follow-up of Abnormal Test Results in a Complex Sociotechnical Environment. Appl Clin Inform 2013; 4 (Suppl. 03) 359-375.
  • 21 Schmidt-Hansen M, Berendse S, Hamilton W. The association between symptoms and bladder or renal tract cancer in primary care: a systematic review. Br J Gen Pr 2015; 65 (Suppl. 640) e769-e775.
  • 22 Murphy DR, Meyer AD, Russo E, Sittig DF, Wei L, Singh H. The Burden of Inbox Notifications in Commercial Electronic Health Records. JAMA Intern Med 2016; 176 (Suppl. 04) 559-560.
  • 23 Nielsen M, Qaseem A. High Value Care Task Force of the American College of Physicians.. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med 2016; 164 (Suppl. 07) 488-497.
  • 24 Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC. “Global Trigger Tool” Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Aff (Millwood) 2011; 30 (Suppl. 04) 581-589.
  • 25 de Wet C, Bowie P. Screening electronic patient records to detect preventable harm: a trigger tool for primary care. Qual Prim Care 2011; 19 (Suppl. 02) 115-125.
  • 26 Kaafarani HMA, Rosen AK, Nebeker JR, Shimada S, Mull HJ, Rivard PE, Savitz L, Helwig A, Shin MH, Itani KMF. Development of trigger tools for surveillance of adverse events in ambulatory surgery. Qual Saf Health Care 2010; 19 (Suppl. 05) 425-429.
  • 27 Rosen AK, Mull HJ, Kaafarani H, Nebeker J, Shimada S, Helwig A, Nordberg B, Long B, Savitz LA, Shanahan CW, Itani K. Applying trigger tools to detect adverse events associated with outpatient surgery. J Patient Saf 2011; 7 (Suppl. 01) 45-59.
  • 28 Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition).. Cambridge, MA: Institute for Healthcare Improvement; 2009. (IHI Innovation Series white paper.). Available from: http://www.ihi.org/resources/pages/ihiwhitepapers/ihiglobaltriggertoolwhitepaper.aspx
  • 29 Rozich J, Haraden C, Resar R. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003; 12 (Suppl. 03) 194-200.
  • 30 Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial. J Clin Oncol 2015; 33 (Suppl. 31) 3560-3567.
  • 31 Kidney E, Berkman L, Macherianakis A, Morton D, Dowswell G, Hamilton W, Ryan R, Awbery H, Greenfield S, Marshall T. Preliminary results of a feasibility study of the use of information technology for identification of suspected colorectal cancer in primary care: the CREDIBLE study. Br J Cancer 2015; 112 (01) S70-S76.
  • 32 Murphy DR, Laxmisan A, Reis BA, Thomas EJ, Esquivel A, Forjuoh SN, Parikh R, Khan MM, Singh H. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf 2014; 23 (Suppl. 01) 8-16.
  • 33 Murphy DR, Thomas EJ, Meyer AND, Singh H. Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings. Radiology 2015; 277 (Suppl. 01) 81-87.
  • 34 Murphy DR, Meyer AND, Bhise V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results. Chest 2016; 150 (Suppl. 03) 613-620.
  • 35 Fihn SD, Francis J, Clancy C, Nielson C, Nelson K, Rumsfeld J, Cullen T, Bates J, Graham GL. Insights from advanced analytics at the Veterans Health Administration. Health Aff Proj Hope 2014; 33 (Suppl. 07) 1203-1211.
  • 36 Loo RK, Lieberman SF, Slezak JM, Landa HM, Mariani AJ, Nicolaisen G, Aspen AM, Jacobsen SJ. Stratifying Risk of Urinary Tract Malignant Tumors in Patients With Asymptomatic Microscopic Hematuria. Mayo Clin Proc 2013; 88 (Suppl. 02) 129-138.
  • 37 Singh H, Sethi S, Raber M, Petersen LA. Errors in Cancer Diagnosis: Current Understanding and Future Directions. J Clin Oncol 2007; 25 (Suppl. 31) 5009-5018.
  • 38 Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims. Ann Intern Med 2006; 145 (Suppl. 07) 488-496.
  • 39 Lorincz C, Drazen E, Sokol P, Neerukonda K, Metzger J, Toepp M, Maul L, Classen D, Wynia M. Research in Ambulatory Patient Safety 2000-2010: A 10-year review.. Chicago IL: American Medical Association; 2011
  • 40 Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care.. Balogh EP, Miller BT, Ball JR. editors. Washington DC: National Academies Press; 2015. [cited 2016 Aug 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK338596
  • 41 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 7494 765.
  • 42 Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication Outcomes of Critical Imaging Results in a Computerized Notification System. J Am Med Inform Assoc 2007; 14 (Suppl. 04) 459-466.

Correspondence to:

Daniel R Murphy, MD MBA
Michael E DeBakey Veterans Affairs Medical Center (MEDVAMC)
Houston Center for Innovations in Quality, Effectiveness & Safety (IQuESt) (152)
2002 Holcombe Boulevard
Houston, TX
77030 USA 713-440–4600 (o), 713-748–7359 (f)

  • References

  • 1 Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015; 136 (Suppl. 05) E359-E386.
  • 2 Hollenbeck BK, Dunn RL, Ye Z, Hollingsworth JM, Skolarus TA, Kim SP, Montie JE, Lee CT, Wood DP, Miller DC. Delays in diagnosis and bladder cancer mortality. Cancer 2010; 116 (Suppl. 22) 5235-5242.
  • 3 Mahmud SM, Fong B, Fahmy N, Tanguay S, Aprikian AG. Effect of Preoperative Delay on Survival in Patients With Bladder Cancer Undergoing Cystectomy in Quebec: A Population Based Study. J Urol 2006; 175 (Suppl. 01) 78-83.
  • 4 Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, Hamilton W, Hendry A, Hendry M, Lewis R, Macleod U, Mitchell ED, Pickett M, Rai T, Shaw K, Stuart N, Tørring ML, Wilkinson C, Williams B, Williams N, Emery J. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer 2015; 112 s1 S92-S107.
  • 5 Bergman J, Neuhausen K, Chamie K, Scales CD, Carter S, Kwan L, Lerman SE, Aronson W, Litwin MS. Building a Medical Neighborhood in the Safety Net: An Innovative Technology Improves Hematuria Workups. Urology 2013; 82 (Suppl. 06) 1277-1282.
  • 6 Lyratzopoulos G, Neal RD, Barbiere JM, Rubin GP, Abel GA. Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol 2012; 13 (Suppl. 04) 353-365.
  • 7 Lyratzopoulos G, Abel GA, McPhail S, Neal RD, Rubin GP. Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey. BMJ Open 2013; 3 (Suppl. 06) e002861.
  • 8 Dobruch J, Daneshmand S, Fisch M, Lotan Y, Noon AP, Resnick MJ, Shariat SF, Zlotta AR, Boorjian SA. Gender and Bladder Cancer: A Collaborative Review of Etiology, Biology, and Outcomes. Eur Urol 2016; 69 (Suppl. 02) 300-310.
  • 9 Cohn JA, Vekhter B, Lyttle C, Steinberg GD, Large MC. Sex disparities in diagnosis of bladder cancer after initial presentation with hematuria: a nationwide claims-based investigation. Cancer 2014; 120 (Suppl. 04) 555-561.
  • 10 Nieder AM, Lotan Y, Nuss GR, Langston JP, Vyas S, Manoharan M, Soloway MS. Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urol Oncol Semin Orig Investig 2010; 28 (Suppl. 05) 500-503.
  • 11 Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, Messing EM, Miller SD, Peterson AC, Turk TMT, Weitzel W. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 2012; 188 s6 2473-2481.
  • 12 Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010; 19 s3 i68-i74.
  • 13 Lyratzopoulos G, Vedsted P, Singh H. Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation. Br J Cancer 2015; 112 s1 S84-S91.
  • 14 Tarkan S, Plaisant C, Shneiderman B, Hettinger AZ. Reducing Missed Laboratory Results: Defining Temporal Responsibility, Generating User Interfaces for Test Process Tracking, and Retrospective Analyses to Identify Problems. AMIA Annu Symp Proc 2011; 1382-1391.
  • 15 Månsson Å, Anderson H, Colleen S. Time Lag to Diagnosis of Bladder Cancer–Influence of Psychosocial Parameters and Level of Health-Care Provision. Scand J Urol Nephrol 1993; 27 (Suppl. 03) 363-369.
  • 16 Chen EH, Bodenheimer T. Improving Population Health Through Team-Based Panel Management: Comment on “Electronic Medical Record Reminders and Panel Management to Improve Primary Care of Elderly Patients.”. Arch Intern Med 2011; 171 (Suppl. 17) 1558-1559.
  • 17 Murphy DR, Reis B, Kadiyala H, Hirani K, Sittig DF, Khan MM, Singh H. Electronic Health Record-Based Messages to Primary Care Providers: Valuable Information or Just Noise?. Arch Intern Med 2012; 172 (Suppl. 03) 283.
  • 18 Murphy DR, Reis B, Sittig DF, Singh H. Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med 2012; 125 (Suppl. 02) 209. e1-7.
  • 19 Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Smith MW, Murphy DR, Espadas D, Laxmisan A, Sittig DF. Primary care practitioners’ views on test result management in EHR-enabled health systems: a national survey. J Am Med Inform Assoc 2013; 20 (Suppl. 04) 727-735.
  • 20 Smith M, Murphy D, Laxmisan A, Sittig D, Reis B, Esquivel A, Singh H. Developing Software to “Track and Catch” Missed Follow-up of Abnormal Test Results in a Complex Sociotechnical Environment. Appl Clin Inform 2013; 4 (Suppl. 03) 359-375.
  • 21 Schmidt-Hansen M, Berendse S, Hamilton W. The association between symptoms and bladder or renal tract cancer in primary care: a systematic review. Br J Gen Pr 2015; 65 (Suppl. 640) e769-e775.
  • 22 Murphy DR, Meyer AD, Russo E, Sittig DF, Wei L, Singh H. The Burden of Inbox Notifications in Commercial Electronic Health Records. JAMA Intern Med 2016; 176 (Suppl. 04) 559-560.
  • 23 Nielsen M, Qaseem A. High Value Care Task Force of the American College of Physicians.. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med 2016; 164 (Suppl. 07) 488-497.
  • 24 Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC. “Global Trigger Tool” Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Aff (Millwood) 2011; 30 (Suppl. 04) 581-589.
  • 25 de Wet C, Bowie P. Screening electronic patient records to detect preventable harm: a trigger tool for primary care. Qual Prim Care 2011; 19 (Suppl. 02) 115-125.
  • 26 Kaafarani HMA, Rosen AK, Nebeker JR, Shimada S, Mull HJ, Rivard PE, Savitz L, Helwig A, Shin MH, Itani KMF. Development of trigger tools for surveillance of adverse events in ambulatory surgery. Qual Saf Health Care 2010; 19 (Suppl. 05) 425-429.
  • 27 Rosen AK, Mull HJ, Kaafarani H, Nebeker J, Shimada S, Helwig A, Nordberg B, Long B, Savitz LA, Shanahan CW, Itani K. Applying trigger tools to detect adverse events associated with outpatient surgery. J Patient Saf 2011; 7 (Suppl. 01) 45-59.
  • 28 Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition).. Cambridge, MA: Institute for Healthcare Improvement; 2009. (IHI Innovation Series white paper.). Available from: http://www.ihi.org/resources/pages/ihiwhitepapers/ihiglobaltriggertoolwhitepaper.aspx
  • 29 Rozich J, Haraden C, Resar R. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care 2003; 12 (Suppl. 03) 194-200.
  • 30 Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial. J Clin Oncol 2015; 33 (Suppl. 31) 3560-3567.
  • 31 Kidney E, Berkman L, Macherianakis A, Morton D, Dowswell G, Hamilton W, Ryan R, Awbery H, Greenfield S, Marshall T. Preliminary results of a feasibility study of the use of information technology for identification of suspected colorectal cancer in primary care: the CREDIBLE study. Br J Cancer 2015; 112 (01) S70-S76.
  • 32 Murphy DR, Laxmisan A, Reis BA, Thomas EJ, Esquivel A, Forjuoh SN, Parikh R, Khan MM, Singh H. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf 2014; 23 (Suppl. 01) 8-16.
  • 33 Murphy DR, Thomas EJ, Meyer AND, Singh H. Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings. Radiology 2015; 277 (Suppl. 01) 81-87.
  • 34 Murphy DR, Meyer AND, Bhise V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results. Chest 2016; 150 (Suppl. 03) 613-620.
  • 35 Fihn SD, Francis J, Clancy C, Nielson C, Nelson K, Rumsfeld J, Cullen T, Bates J, Graham GL. Insights from advanced analytics at the Veterans Health Administration. Health Aff Proj Hope 2014; 33 (Suppl. 07) 1203-1211.
  • 36 Loo RK, Lieberman SF, Slezak JM, Landa HM, Mariani AJ, Nicolaisen G, Aspen AM, Jacobsen SJ. Stratifying Risk of Urinary Tract Malignant Tumors in Patients With Asymptomatic Microscopic Hematuria. Mayo Clin Proc 2013; 88 (Suppl. 02) 129-138.
  • 37 Singh H, Sethi S, Raber M, Petersen LA. Errors in Cancer Diagnosis: Current Understanding and Future Directions. J Clin Oncol 2007; 25 (Suppl. 31) 5009-5018.
  • 38 Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims. Ann Intern Med 2006; 145 (Suppl. 07) 488-496.
  • 39 Lorincz C, Drazen E, Sokol P, Neerukonda K, Metzger J, Toepp M, Maul L, Classen D, Wynia M. Research in Ambulatory Patient Safety 2000-2010: A 10-year review.. Chicago IL: American Medical Association; 2011
  • 40 Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care.. Balogh EP, Miller BT, Ball JR. editors. Washington DC: National Academies Press; 2015. [cited 2016 Aug 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK338596
  • 41 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 7494 765.
  • 42 Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. Communication Outcomes of Critical Imaging Results in a Computerized Notification System. J Am Med Inform Assoc 2007; 14 (Suppl. 04) 459-466.