Diagnostic Safety Centers of Excellence

Diagnostic Accuracy Through Advancing EHR displaY, Education, and Surveillance (DATA-EYES)

Principal Investigators:

• Jeffrey A. Gold, Oregon Health and Science University
• David W. Bates, Brigham and Women's Hospital
• Raj M. Ratwani, MedStar Health Research Institute

Grant Number: 1R18HS029345-01

Goals:

The goal of the DATA-EYES Diagnostic Center of Excellence is to establish an infrastructure to systematically collect data on how, when, and why the electronic health record (EHR) contributes to diagnostic error. This information can be used to create a series of interventions to address gaps in training, software, and workflow and to standardize and optimize EHR design and use to achieve diagnostic excellence.

Project Aims:

1. Expand on our preliminary work in ambulatory care and analyze data from two national patient safety event databases (Collaborative Healthcare Patient Safety Organization, Patient Safety Authority) and medical malpractice reports (CRICO) to create a taxonomy to classify the contribution of electronic health records (EHRs) to diagnostic error that spans all major specialties and care environments.
2. Integrate the taxonomy into currently deployed event reporting systems.
3. Use data gathered from error reporting to facilitate implementation of a multiparameter strategy that improves EHR use to promote diagnostic excellence.

Armstrong Institute Center for Diagnostic Excellence – Pursuing Scalable System-Level Diagnostic Quality, Value, and Equity by Applying Safety Science to Emergency Department Diagnosis

Principal Investigators:

• David Newman-Toker, Johns Hopkins University
• Kathryn Mack McDonald, Johns Hopkins University

Grant Number: 1R18HS029350-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of the Armstrong Institute Center for Diagnostic Excellence, is to expand the activities of an existing academic center for diagnostic excellence whose focus is to eliminate patient harms from diagnostic error. Projects supported by this proposal will focus on achieving diagnostic excellence in the emergency department through research and quality improvement activities, including:

• Clinical programs to eliminate stroke misdiagnosis,
• New methods of diagnostic error incident reporting by physicians, and
• A software tool to help measure the projected return on investment for new diagnostic strategies that will help spread these innovations.

Project Aims:

1. Target immediate efforts to address the top causes of serious misdiagnosis-related harms in the ED.
2. Partner and share knowledge with other entities both within and beyond the network of centers of diagnostic excellence.
3. Develop a Johns Hopkins organizational framework for growth and sustainability of the center for diagnostic excellence mission.

Publications:

Tarnutzer AA, Gold D, Wang Z, Robinson KA, Kattah JC, Mantokoudis G, Saber Tehrani AS, Zee DS, Edlow JA, Newman-Toker DE. Impact of clinician training background and stroke location on bedside diagnostic test accuracy in the acute vestibular syndrome - a meta-analysis. Ann Neurol. 2023 Aug;94(2):295-308. Epub 2023 Apr 27. https://pmc.ncbi.nlm.nih.gov/articles/PMC10524166/.

Achieving Better Cancer Diagnosis (ABCD): Identifying, Supporting, and Learning From Marginalized Patients Who Experience Delayed Cancer Diagnosis

Principal Investigators:

• Gordon David Schiff, Brigham and Women’s Hospital
• Thomas Henry Gallagher, University of Washington Medical Center

Grant Number: 1R18HS029344-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of the Achieving Better Cancer Diagnosis Diagnostic Center of Excellence is to prevent delays in cancer diagnosis. The center will detect delays in cancer diagnosis in real time, especially among marginalized patients, and then learn deeply from them about what went wrong, how delays could be avoided, and what strategies could mitigate any harm that has occurred. This diagnostic center of excellence will bring together national experts on diagnostic safety (Brigham and Women’s Hospital/Harvard Medical School) and on communication and resolution programs (University of Washington) to seek out and address cases and causes of delayed diagnosis of cancer.

Project Aims:

1. Create a center of diagnostic excellence that will design and implement a program to identify and learn from patients with delays in diagnosis of four leading cancers.
2. Engage and deeply learn from patients who have experienced delayed cancer diagnoses.
3. Advance, implement, and evaluate generalizable interventions to improve the cancer diagnostic process.

DECODE: Diagnostic Excellence Center on Diagnostic Error

Principal Investigators:

• Ramin Khorasani, Brigham and Women's Hospital
• Ronilda Lacson, Brigham and Women's Hospital

Grant Number: 1R18HS029348-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of DECODE: Diagnostic Excellence Center on Diagnostic Error is to decrease diagnostic errors in medical imaging by implementing and evaluating a highly resilient system for care planning and coordination, as well as a peer learning system for clinical providers.

Project Aims:

1. Develop a multidisciplinary diagnostic excellence center to address diagnostic errors.
2. Design enhancements to a pilot implementation of a highly reliable and resilient system, accelerate its implementation in a large healthcare system, and evaluate its impact on diagnostic errors using a mixed-methods analysis.
3. Improve diagnostic precision and management by building consensus using available evidence.
4. Disseminate all DECODE methods and tools, including specifications for information technology systems and workflow processes.

Publications:

Abbasi N, Lacson R, Kapoor N, Licaros A, Guenette JP, Burk KS, Hammer M, Desai S, Eappen S, Saini S, Khorasani R. Development and external validation of an artificial intelligence model for identifying radiology reports containing recommendations for additional imaging. AJR Am J Roentgenol. 2023 Sep;221(3):377-385. Epub 2023 Apr 19. https://pubmed.ncbi.nlm.nih.gov/37073901/.

DeSimone AK, Kapoor N, Lacson R, Budiawan E, Hammer MM, Desai SP, Eappen S, Khorasani R. Impact of an automated closed-loop communication and tracking tool on the rate of recommendations for additional imaging in thoracic radiology reports. J Am Coll Radiol. 2023 Aug;20(8):781-788. https://pubmed.ncbi.nlm.nih.gov/37307897/.

The Patient-Partnered Diagnostic Center of Excellence

Principal Investigators:

• Kristen Elizabeth Miller, MedStar Health Research Institute
• Traber L. Giardina, Baylor College of Medicine
• Kelly Michelle Smith, University of Toronto

Grant Number: 1R18HS029356-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of the Patient-Partnered Diagnostic Center of Excellence is to shift the current focus on the clinician as the center of both the problems and the solutions to diagnostic errors by convening diverse scientists and patients around research questions developed and prioritized by patients. These gatherings will yield patient-centered diagnostic safety solutions and reductions in the number of adverse diagnostic safety events. By measuring the problem (Safety-I) and devising solutions to build diagnostic team resilience (Safety-II), this center will develop clear evidence that can improve diagnostic safety for all patients in the United States.

Project Aims:

1. Create and execute research in four workstreams of the center that detect and address the contributing factors leading to diagnostic errors, informed by patient partners.
2. Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors.
3. Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error in simulated and clinical environments, disseminate solutions, and develop a sustainability plan.

ADVANCE [Advancing Diagnosis through Validated Analytics and Novel Collaborations for Excellence]

Principal Investigators:

• Goutham Rao, University Hospitals of Cleveland
• Mary Dolansky, Case Western Reserve University
• Marlene Rosemary Miller, University Hospitals
• Peter J. Pronovost, University Hospitals

Grant Number: 1R18HS029358-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of the ADVANCE Diagnostic Center of Excellence is to tackle diagnostic problems using a data- and consensus-driven approach. The center plans to assemble a diverse, multidisciplinary team to provide formal input about standards and best practices and implement a 4-step strategy to develop recommended diagnostic practices. The center will sustain itself by creating policies, methods, a future agenda, and partnerships within and outside the center's organization.

Project Aims:

1. Identify current evidence, diagnostic practices, and outcomes for the problems of unintentional weight loss, high blood pressure, and sepsis.
2. Develop recommendations for improved diagnostic practices for the clinical problems above, based on analysis of EHR data; existing evidence, including from a home blood pressure monitoring screening study; and input and consensus among clinicians and patients.
3. Disseminate and implement recommendations through a multifaceted approach using quality improvement principles and evaluating key outcomes including timeliness, accuracy, and resource use associated with diagnosis.

Publications:

Rao G, Ufholz K, Saroufim P, Menegay H, Beno M. Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care. Diagnosis (Berl). 2023 Apr 21;10(3):267-274. https://pmc.ncbi.nlm.nih.gov/articles/PMC11661681/.

Safety-II Together: Coupling Teaming Science With Patient Engagement and Health Information Transparency To Coproduce Diagnostic Excellence

Principal Investigators:

• Eric J Thomas, University of Texas Health Science Center, Houston
• Sigall Bell, Beth Israel Deaconess Medical Center

Grant Number: 1R18HS029362-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of the Safety-II Together Diagnostic Center of Excellence is to identify specific teaming behaviors that help patients and healthcare providers coproduce safety at known diagnostic process risk points. The next step is to develop and disseminate tools that support patients, care partners, interpreters, and clinicians as active contributors to the diagnostic process.

Project Aims:

1. Conduct diagnostic ecosystem mapping, using qualitative methods and a Safety-II lens, guided by teaming science principles and known patient-identified blind spots.
2. Elevate less heard voices in the diagnostic process at the frontlines of care, including patients with limited English proficiency and older patients with chronic illness, through teaming tools.
3. Build capacity to sustain and expand multistakeholder diagnostic Safety-II contributions through a novel center of diagnostic excellence program: "Safety2gether."

Publications:

Liu SK, Bourgeois F, Dong J, Harcourt K, Lowe E, Salmi L, Thomas EJ, Riblet N, Bell SK. What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process. Diagnosis (Berl). 2023;11(1):63-72. https://pmc.ncbi.nlm.nih.gov/articles/PMC10875277/.

Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT)

Principal Investigators:

• Andrew D. Auerbach, University of California, San Francisco
• Jeffrey Lawrence Schnipper, Brigham and Women's Hospital

Grant Number: 1R18HS029366-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goals of the ADEPT Diagnostic Center of Excellence are to link a group of hospitals to measure and share the rates of diagnostic error, understand underlying causes of diagnostic errors, and develop ways hospitals, clinicians, and patients can work together to avoid diagnostic errors and their resulting harms. This center will test whether data sharing and collaboration improve diagnostic processes and develop approaches that can be sustained into the future.

Project Aims:

1. Implement an enhanced case review infrastructure that can accurately identify diagnostic errors and characterize diagnostic processes among patients who experience inpatient deaths, ICU transfers, or rapid-response team calls taking place at hospitals associated with UPSIDE.
2. Develop site-level and groupwide benchmarking reports of error rates, diagnostic processes, and diagnostic performance and incorporate them into sites’ safety and quality programs.
3. Use Aim 2 infrastructure to identify and pilot Safety-I and Safety-II interventions.
4. Carry out a comprehensive program evaluation, including analysis of rates of diagnostic errors and process faults before and after implementation of our Aim 1 and 2 programs and analysis of reach, effectiveness, adoption, implementation, and maintenance of Aim 1 and 2 programs and Aim 3 pilot interventions.

Publications:

Auerbach AD, Lee TM, Hubbard CC, Ranji SR, Raffel K, Valdes G, Boscardin J, Dalal AK, Harris A, Flynn E, Schnipper JL; UPSIDE Research Group. Diagnostic errors in hospitalized adults who died or were transferred to intensive care. JAMA Intern Med. 2024;184(2):164-173. https://pmc.ncbi.nlm.nih.gov/articles/PMC10775080/.

Schnipper JL, Raffel KE, Keniston A, Burden M, Glasheen J, Ranji S, Hubbard C, Barish P, Kantor M, Adler-Milstein J, John Boscardin W, Harrison JD, Dalal AK, Lee T, Auerbach A. Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: a multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients. J Hosp Med. 2023 Dec;18(12):1072-1081. Epub 2023 Oct 27. https://pmc.ncbi.nlm.nih.gov/articles/PMC10964432/.

Re-Engineering Patient and Family Communication To Improve Diagnostic Safety Resilience

Principal Investigators:

• Kathleen Elizabeth Walsh, Boston Children's Hospital
• Christopher Paul Landrigan, Boston Children's Hospital

Grant Number: 1R18HS029346-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goals of the Re-Engineering Patient and Family Communication To Improve Diagnostic Safety Resilience Diagnostic Center of Excellence are to characterize the diagnostic journey among children with multiple chronic conditions using Safety-I and Safety-II approaches. The center will also focus on patient/family-clinician communication and work to adapt and test the impact of an outpatient structured family-centered communication intervention (PFC I-PASS) on diagnostic success, errors, and harm.

Project Aims:

1. Characterize the diagnostic journey, focusing on successes, errors, and patient/family and clinician communication.
2. Adapt PFC I-PASS to create Outpatient PFC I-PASS, a structured communication intervention for patients/families and clinicians in the outpatient setting.
3. Evaluate the effectiveness of PFC I-PASS (discharge and outpatient) to improve patient/family and clinician communication and experience and to reduce errors and harm throughout the diagnostic journey.

Diagnostic Safety Center for Advancing E-Triggers and Rapid Feedback Implementation (DISCOVERI)

Principal Investigator: Hardeep Singh, Baylor College of Medicine

Grant Number: 1R18HS029347-01

Project Period: 09/30/22 - 09/29/26

Goals: 

The goal of DISCOVERI is to implement methods to help organizations electronically identify patients who may have experienced errors and delays in diagnosis and understand why they occurred. This center will create new knowledge, tools, and strategies that healthcare organizations can use to learn how to prevent and reduce harm from diagnostic error.

Project Aims:

1. Create tools, strategies, and methods to implement e-trigger algorithms for diagnostic error surveillance and prevention in LEDE (Learning and Exploration of Diagnostic Excellence) organizations.
2. Develop and evaluate Safety-I- and Safety-II-related methods for providing clinicians and healthcare organizations with rapid diagnostic performance feedback.
3. Synthesize implementation experiences to develop a safety surveillance system, "Safer Dx e-Watch," to facilitate large-scale implementation efforts in U.S. health systems.

Publications:

Sloane J, Singh H, Upadhyay DK, Korukonda S, Marinez A, Giardina TD. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab. Jt Comm J Qual Patient Saf. Epub 2024 May 31. https://pubmed.ncbi.nlm.nih.gov/38944572/.

Harada Y, Kawamura R, Yokose M, Shimizu T, Singh H. Definitions and measurements for atypical presentations at risk for diagnostic errors in internal medicine: protocol for a scoping review. JMIR Res Protoc. 2024 Mar 25;13:e56933. https://pmc.ncbi.nlm.nih.gov/articles/PMC11002735/.

Khalaf N, Ali B, Liu Y, Kramer JR, El-Serag H, Kanwal F, Singh H. Emergency presentations predict worse outcomes among patients with pancreatic cancer. Dig Dis Sci. 2024 Feb;69(2):603-614. Epub 2023 Dec 16. https://pubmed.ncbi.nlm.nih.gov/38103105/.

Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023 Oct;38(Suppl 4):940-942. https://pmc.ncbi.nlm.nih.gov/articles/PMC10593716/.

Murphy DR, Zimolzak AJ, Upadhyay DK, Wei L, Jolly P, Offner A, Sittig DF, Korukonda S, Rekha RM, Singh H. Developing electronic clinical quality measures to assess the cancer diagnostic process. J Am Med Inform Assoc. 2023 Aug 18;30(9):1526-1531. https://pmc.ncbi.nlm.nih.gov/articles/PMC10436145/.

Kulkarni PA, Singh H. Artificial intelligence in clinical diagnosis: opportunities, challenges, and hype. JAMA. 2023 Jul 25;330(4):317-318. https://doi.org/10.1001/jama.2023.11440.