The overall objective of this project is to design, test and implement an automated system which monitors health care delivery processes to identify potential breakdowns in follow-up care for patients with life threatening conditions. Patients with abnormal tests and clinical findings, showing potentially life-threatening conditions, do not get follow-up, those diagnosed may not get appropriate initial treatment, and others are not properly managed over the extended periods of time necessary to gain the potential additional years of quality living. These failures are accentuated in minority populations because of lack of physician continuity over time, under-resourced provider systems, language and cultural communication differences with providers, lack of health education among patients, and other stressors which contribute to sub-optimal care. The initial focus is on conditions involving abnormal findings on chest x-ray indicative of lung cancers, and abnormal prostate cancer screening and diagnostic tests; these cancers are more prevalent among minorities. On average, they are discovered at later stages of disease and do not receive as early or extensive interventions. While individual failures leading to worse outcomes can occur at multiple different points, some of the most egregious examples are: failure to review interpreted results of screening tests; failure to recommend/order appropriate follow-up abnormal test results or findings; and failure to detect sub-optimal therapy interventions. US CareLink (USCL) LLC, in collaboration with Boston Medical Center (the leading safety net hospital in New England) and its HealthNet community health centers, proposes to develop and demonstrate, for inner-city minority populations, a computer-based tool called TRACR (Tracking Results/Findings, Alerts and Clinical Responses). As a care monitoring tool, TRACR is designed to go beyond simple reminders and alerts to busy clinicians. It seeks to close the loop in key processes of care for a disease problem longitudinally across a patient's lifetime. The system actively identifies unresolved actions in the care process, notifies clinicians and/or patients of these, and continues to monitor the response of the clinicians and patients. During Phase 1, the underlying software technology will be developed, the clinical rules for monitoring and follow-up will be designed, and the system tested in a simulated environment. In Phase 2, an experimental field trial of TRACR problem detection and intervention from initial screening through initial full course of therapy will be conducted. The system will be implemented for half of the primary care clinics and community health centers with comparison of rates of patients having proper follow-up care compared to those with """"""""usual care."""""""" If proven for these two problems, TRACR can be applied to many other clinical conditions where follow-up failures occur, causing avoidable morbidity and mortality, particularly in minority populations. Other candidates for future intervention include breast cancer, colon cancer, diabetes, osteoporosis and hypertension.
The software system proposed to being developed under this project aims to improve the followup of care in a variety of clinical conditions. The emphasis is on those clinical conditions and scenarios that disproportionately affect minority patients. The software will monitor asynchronously patient's clinical data and when events requiring followup are detected, but the followup action has not been performed, the software system will contact the physician or the patient or both as appropriate to insure that followup occurs.. ? ? ? ?
