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Acknowledgements. PI Amy Rosen, PhDCo-PI Jonathan Nebeker, MD, MSCo-Investigators:Stephan Gaehde, MDHaytham Kaafarani, MD, MPHBrenna Long, MAHillary Mull, MPPBrian Nordberg, BSSteve Pickard, MSPeter Rivard, PhDLucy Savitz, PhD, MBAChris Shanahan, MD, MPHStephanie Shimada, PhD
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1. Development and Use of Ambulatory Adverse Event Trigger ToolsAmy K. Rosen, PhD AHRQ Conference Sept. 14, 2009
2. Acknowledgements
PI Amy Rosen, PhD
Co-PI Jonathan Nebeker, MD, MS
Co-Investigators:
Stephan Gaehde, MD
Haytham Kaafarani, MD, MPH
Brenna Long, MA
Hillary Mull, MPP
Brian Nordberg, BS
Steve Pickard, MS
Peter Rivard, PhD
Lucy Savitz, PhD, MBA
Chris Shanahan, MD, MPH
Stephanie Shimada, PhD
3. Project Goal and Settings Goal: Develop adverse event (AEs) triggers for the outpatient setting
Outpatient surgery
Outpatient adverse drug events (ADEs)
Three sites for patient data:
Boston Medical Center (BMC)
Intermountain Healthcare
Veterans Health Administration (VA)
4. Background Triggers are algorithms that use electronic patient data to identify patterns consistent with a possible adverse event
e.g. , the combination of a lab value threshold and an active prescription
Global vs. AE specific trigger:
Flags the chart for the suspicion of occurrence of any AE or the occurrence of a specific AE
Interventionist triggers:
Mostly ADEs
Gives providers a chance to respond and avoid alert overload
5. Methods
6. Methods
7. Methods
8. Methods
9. Methods
10. Methods Obtained de-identified clinical data from each site
Combined the data fields from each site into a SQL database
Created a mock electronic medical record (EMR) interface to enable case classification
11. Global Trigger Tools – Outpatient Surgery
12. AE-Specific Trigger Tools – Outpatient Surgery
13. Surgery Trigger Logic: Procedure Fire if:
Same-day surgery
AND
procedure (interventional radiological OR urological OR cardiac OR gastroenterological)
OR re-operation = 30 days
14. AE-Specific Trigger Tools – ADE
15. AE-Specific Trigger Tools – ADE (cont’d)
16. ADE Trigger Logic: Change in Renal Clearance Fire if:
Subsequent increase in creatinine > 33% and dose > than dose prior to creatinine measurement (This is the reference creatinine level) AND
NOT (trimethoprim started in interval between 1 day prior to creatinine measurement and after reference creatinine level) AND
NOT (all GFR reducers and renal toxins discontinued or expired > 3 months prior to triggering value)
Remove trigger if response taken within window:
Renal toxin discontinued or GFR reducer dose reduced 0-6 days after firing criteria satisfied OR
Creatinine resulted 0-6 days after firing criteria satisfied
17. Data Challenges – Accessing Data Political/Logistical Barriers
Gaining permission to access the data
Developed de-identification algorithm
Challenge meeting HIPAA compliance
Administrative barriers to obtaining access
Encrypting/ ensuring safe transfer of data between sites
Safe storage of data from multiple institutions
IT Resources
Availability of personnel for data pulls
Computing infrastructures
Pulling notes too resource intensive
18. Data Challenges – Data Elements “IT Black Box”
Researchers reliant on IT staff’s programming, no way to ascertain completeness of data
Inconsistencies in coding across institutions
Same information, different coding:
Gender: M/F vs 1/2/3
Units of measure: metric vs US vs missing
ICD-9-CM codes stored with or without periods
ICD-9-CM procedure codes were unavailable for some procedures
Lab titles inconsistent across settings
Lack of documentation re: coding practices
Numeric results within text data
19. Data Challenges – Data Elements (cont’d) Missing data
Loss of information from text de-identification algorithm
Fuzzy pattern and word matching removed some key clinical terms from clinical notes
De-identification made notes difficult to read
Removal of dates resulted in loss of information about clinical order
Missing National Drug Codes (NDCs) in pharmacy data
Free text vs. standardized daily dosage information
TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR 2 WEEKS, THEN TAKE ONE-HALF TABLET TWO (2) TIMES A DAY FOR 2 WEEKS, THEN TAKE ONE TABLET TWO (2) TIMES A DAY FOR 2 WEEKS, THEN TAKE TWO TABLETS TWO (2) TIMES A DAY FOR 2 WEEKS, THEN TAKE THREE TABLETS TWO (2) TIMES A DAY FOR 2 WEEKS, THEN TAKE FOUR TABLETS TWO (2) TIMES A DAY INCREASE DOSE GRADUALLY. WHEN GOING FROM 25 TO 50 MG START WITH INCREASING THE AM DOSE FOR 2WEEKS, THEN THE AM AND PM DOSE. DO THIS WHEN INCREASING FROM 50 TO 75 AND 75 TO 100. IF QUESTIONS PLEASE CALL.
Lack of units in lab data
20. Next Steps Case classification
RNs classifying surgery AE trigger-flagged cases
Pharmacists classifying ADE trigger-flagged cases
Calculate positive predictive value (PPV) for each trigger
Conduct a second round of focus groups at each institution
Hold phone call with trigger experts to review logic and discuss results
21. Dissemination to Date Triggers and Targeted Injury Detection Systems (TIDS)Expert Panel Meeting , Rockville, MD. June 2008. See proceedings at http://www.ahrq.gov/QUAL/triggers/
Mull HJ & Nebeker, JR. Informatics Tools for the Development of Triggers for Outpatient Adverse Drug Events. AMIA Annual Symposium Proceedings. Nov 2008, 6:505-9.
Kaafarani H, Rosen AK, et al. What is a Trigger Tool to a Surgeon: Designing Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery. Massachusetts Chapter of the American College of Surgeons 55th Annual Meeting, Boston, MA. Dec 2008.
Kaafarani H, Rosen AK, et al. Development of Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery. VA HSR&D QUERI National Meeting, Phoenix, AZ. Dec 2008.
Kaafarani H, Rosen AK, et al. Developing Trigger Tools for Surveillance of Adverse Events in Same-Day Surgery: A Literature-Based, End-User Inspired & Expert-Evaluated Methodology. VA HSR&D Annual Meeting, Baltimore, MD. Feb 2009.
Shimada S, Rivard P, et al. Priorities & Preferences of Potential Ambulatory Trigger Tool Users. AcademyHealth Annual Research Meeting, Chicago, IL. June 2009.
Kaafarani H, Rosen AK, et al. Developing Trigger Tools for Surveillance of Adverse Events in Same-Day Surgery: A Literature-Based, End-User Inspired and Expert-Evaluated Methodology. AHRQ Annual Meeting, Bethesda, MD. Sept 2009.
Kaafarani H, Rosen AK, et al. Development of Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery. Quality and Safety in Health Care. (forthcoming)