Monitoring High-risk Conditions and Treatments

The Problem

Despite the well-established risks of missed monitoring across multiple clinical situations, solutions are still lacking. Missed monitoring for high-risk conditions can lead to preventable harm and indeed, lack of needed monitoring is often cited in closed outpatient malpractice claims.  As an example, patients receiving anti-coagulation medication require periodic blood tests and the results of those tests often lead to dose adjustment. Failure to obtain blood tests may lead to under-dosing, which is associated with the risk of blood clots, or over-dosing, which can be associated with bleeding.

Proactive and efficient strategies to detect high-risk situations, such as over-due blood tests, in ambulatory care are urgently needed. The fragmentation of care in ambulatory health systems constitutes a major barrier to patient safety, and in safety-net health systems where patients experience unique barriers to health care, exacerbated by health systems that have a less robust health information technology (HIT) infrastructure, these safety risks are likely to be even greater.

The widespread deployment of HIT creates an opportunity to address safety problems at the health system level, using HIT to detect safety problems in real time. In parallel, the growth of the Patient Centered Medical Home (PCMH) movement provides an opportunity to move beyond visit-based care. A hallmark of the PCMH movement is the timely use of electronic data to inform healthcare needs for a specific patient population and facilitate active monitoring, management, and outreach. Critically, HIT functionality should be paired with team-based workflow which does not require the physician to solely maintain responsibility for timely care. This population-based, team panel management approach can be employed to integrate ambulatory patient safety surveillance into ambulatory care. PCMH models have the potential to reduce disparities in population health and improve safety if implemented in safety-net settings.

Our Proposed Solution

We aim to leverage the growing HIT infrastructure and expertise, as well as the workflow and organizational transformation of the PCMH movement to achieve optimal monitoring of high-risk conditions for outpatients in the SFHN. We are specifically focusing on monitoring the following high-risk conditions and treatments: anticoagulation therapy, incidentally discovered pulmonary nodules, rheumatology, and screening and surveillance for colorectal, breast, cervical, head and neck, and prostate cancers.

The specific aims of this project include: 

  1. To conduct robust problem analysis to optimize monitoring for high-risk conditions across primary and subspecialty outpatient care settings in the San Francisco Health Network. 
  2. To design and develop technical and workflow solutions to ensure that populations with high-risk conditions or receiving high-risk treatments are appropriately undergoing monitoring, which includes not only observation but also needed periodic diagnostic testing. 
  3. To implement a high-risk monitoring safety solution and assess its feasibility in outpatient primary care and specialty care settings in the San Francisco Health Network. 
  4. To evaluate the effectiveness of a high-risk monitoring safety solution in providing real-time intervention in high-risk ambulatory conditions. 

The image above depicts the existing workflow in a clinic, identifying where patients are lost to follow-up, as well as a proposed workflow utilizing a registry system and the PCMH model to monitor patients undergoing high-risk treatments.