Abstract：
BACKGROUND: The COVID-19 pandemic advanced the use of telehealth-facilitated care. However, little is known about how to measure safety of clinical diagnosis made through telehealth-facilitated primary care.
METHODS: We used the seven-step Safer Dx Trigger Tool framework to develop an electronic trigger (e-trigger) tool to identify potential missed opportunities for more timely diagnosis during primary care telehealth visits at a large Department of Veterans Affairs facility. We then applied the e-trigger algorithm to electronic health record data related to primary care visits during a 1-year period (1 April 2020-31 March 2021). The algorithm identified patients with unexpected visits within 10 days of an index telemedicine visit and classified such records as e-trigger positive. We then validated the e-trigger\'s ability to detect missed opportunities in diagnosis using chart reviews based on a structured data collection instrument (the Revised Safer Dx instrument).
RESULTS: We identified 128,761 telehealth visits (32,459 unique patients), of which 434 visits led to subsequent unplanned emergency department (ED), hospital, or primary care visits within 10 days of the index visit. Of these, 116 were excluded for clinical reasons (trauma, injury, or childbirth), leaving 318 visits (240 unique patients) needing further evaluation. From these, 100 records were randomly selected for review, of which four were falsely flagged due to invalid data (visits by non-providers or those incorrectly flagged as completed telehealth visits). Eleven patients had a missed opportunity in diagnosis, yielding a positive predictive value of 11%.
CONCLUSIONS: Electronic triggers that identify missed opportunities for additional evaluation could help advance the understanding of safety of clinical diagnosis made in telehealth-enabled care. Better measurement can help determine which patients can safely be cared for via telemedicine versus traditional in-person visits.
METHODS: We used the seven-step Safer Dx Trigger Tool framework to develop an electronic trigger (e-trigger) tool to identify potential missed opportunities for more timely diagnosis during primary care telehealth visits at a large Department of Veterans Affairs facility. We then applied the e-trigger algorithm to electronic health record data related to primary care visits during a 1-year period (1 April 2020-31 March 2021). The algorithm identified patients with unexpected visits within 10 days of an index telemedicine visit and classified such records as e-trigger positive. We then validated the e-trigger\'s ability to detect missed opportunities in diagnosis using chart reviews based on a structured data collection instrument (the Revised Safer Dx instrument).
RESULTS: We identified 128,761 telehealth visits (32,459 unique patients), of which 434 visits led to subsequent unplanned emergency department (ED), hospital, or primary care visits within 10 days of the index visit. Of these, 116 were excluded for clinical reasons (trauma, injury, or childbirth), leaving 318 visits (240 unique patients) needing further evaluation. From these, 100 records were randomly selected for review, of which four were falsely flagged due to invalid data (visits by non-providers or those incorrectly flagged as completed telehealth visits). Eleven patients had a missed opportunity in diagnosis, yielding a positive predictive value of 11%.
CONCLUSIONS: Electronic triggers that identify missed opportunities for additional evaluation could help advance the understanding of safety of clinical diagnosis made in telehealth-enabled care. Better measurement can help determine which patients can safely be cared for via telemedicine versus traditional in-person visits.
摘要：
背景：COVID-19大流行推进了远程医疗辅助医疗的使用。然而,关于如何衡量通过远程医疗辅助初级保健进行的临床诊断的安全性知之甚少.
方法：我们使用七步安全Dx触发工具框架开发了一种电子触发（e-trigger）工具，以识别潜在的错失机会，以便在大型退伍军人事务部设施的初级保健远程健康访问期间进行更及时的诊断。然后，我们将电子触发算法应用于1年期间（2020年4月1日至2021年3月31日）与初级保健就诊相关的电子健康记录数据。该算法在索引远程医疗访问后10天内识别出意外访问的患者，并将此类记录分类为电子触发阳性。然后，我们使用基于结构化数据收集仪器（修订版SaferDx仪器）的图表审查验证了电子触发器在诊断中检测错失机会的能力。
结果：我们确定了128,761次远程健康访问（32,459例独特患者），其中434次访问导致随后的计划外急诊科(ED)，医院,或索引访视后10天内的初级保健访视。其中,116例因临床原因被排除在外(创伤，损伤,或分娩)，留下318次就诊(240例独特患者)需要进一步评估。从这些,随机选择100条记录进行审查，其中四个由于无效数据而被错误标记（非提供者的访问或那些错误标记为已完成的远程医疗访问）。11名患者错过了诊断机会，产生11%的阳性预测值。
结论：识别错失的额外评估机会的电子触发因素可能有助于提高对远程医疗支持护理中临床诊断安全性的理解。与传统的亲自就诊相比，更好的测量可以帮助确定哪些患者可以通过远程医疗得到安全护理。
方法：我们使用七步安全Dx触发工具框架开发了一种电子触发（e-trigger）工具，以识别潜在的错失机会，以便在大型退伍军人事务部设施的初级保健远程健康访问期间进行更及时的诊断。然后，我们将电子触发算法应用于1年期间（2020年4月1日至2021年3月31日）与初级保健就诊相关的电子健康记录数据。该算法在索引远程医疗访问后10天内识别出意外访问的患者，并将此类记录分类为电子触发阳性。然后，我们使用基于结构化数据收集仪器（修订版SaferDx仪器）的图表审查验证了电子触发器在诊断中检测错失机会的能力。
结果：我们确定了128,761次远程健康访问（32,459例独特患者），其中434次访问导致随后的计划外急诊科(ED)，医院,或索引访视后10天内的初级保健访视。其中,116例因临床原因被排除在外(创伤，损伤,或分娩)，留下318次就诊(240例独特患者)需要进一步评估。从这些,随机选择100条记录进行审查，其中四个由于无效数据而被错误标记（非提供者的访问或那些错误标记为已完成的远程医疗访问）。11名患者错过了诊断机会，产生11%的阳性预测值。
结论：识别错失的额外评估机会的电子触发因素可能有助于提高对远程医疗支持护理中临床诊断安全性的理解。与传统的亲自就诊相比，更好的测量可以帮助确定哪些患者可以通过远程医疗得到安全护理。
