Overview of SureNet

The SureNet program identifies test results or symptoms/signs that generally require follow up but the patients do not appear to have had the needed follow up. It thus potentially prevents diagnostic errors by preventing patients from “falling through the cracks." It is limited to diseases in which their time course of progression is slow enough that one can take a few weeks to identify the cases and intervene.

SureNet is used in eight regions in Kaiser Permanente, covering 12 million patients as well as at Brigham Women’s Hospital.

 

Feasibility/Logistics

Culture: Physicians must be willing to receive notices of possible lapses in care in their practice that may point to physician errors and/or may be false positive notices. There also must be some tolerance that the system will still not be 100% effective.

Infrastructure: Best works in an integrated delivery system but can work in systems with less integration. So far, it has only been implemented in places with an EMR. It will require a small amount of staff to manage the program along with a physician in charge of the program.

Which stakeholders are essential for the tool to be implemented? Physician leaders from each department impacted by the program as well as physician content experts in any area covered by the SureNet (e.g. if the SureNet is addressing a laboratory result like creatinine, stakeholders would include nephrologists and primary care physicians).

 

Implementation

Cost (human and technical): Varies with the exact sure net program but can be low if the system is well integrated and has access to data such that manual review of cases is not required.

Location of usage (ambulatory vs inpatient): Mostly ambulatory but can include ED and hospital as long as any test result generated does not require urgent action.

Role out plan: Any role out plan can be implemented piecemeal starting with just one SureNet and it can start in just one location at a time.

 

Post-Implementation Status

Current status (partly adopted or widely adopted): Widely adopted throughout Kaiser Permanente covering over 12 million patients with some variation in which test results/findings have been spread. It is also been adopted at the Brigham Women and Children's Hospital for several SureNet programs.

Limitations: The SureNet programs identify failure to follow up tests or symptoms but demonstration that such identification has improved patient outcomes is generally lacking except for drug induced hyponatremia. The design of the program is such that specificity is preferred over sensitivity and as a result, this program is not 100% effective at closing the loop. Some patient anxiety/anger may be generated when finding missed result follow up.

Magnitude of benefit if available/Outcome measures: Test result and symptoms have been closed on several million patients with finding cancers of the prostate, lung, urinary bladder, and colon. Malpractice cases have been decreased for delay in diagnosis of prostate cancer with identifying over 700 cases of prostate cancer. Cases of chronic kidney disease, drug induced hyponatremia, post splenectomy state, chlamydia infections, new born hearing loss and hepatitis C have been identified. Hyponatremia-related hospitalizations have been decreased.

Sustainability/Viability: The program started in 2010 and has grown and spread within Kaiser Permanente.

 

References

Danforth KN, Smith AE, Loo RK, Jacobesen SJ, Mittman BS, Kanter MH. Electronic clinical surveillance to improve outpatient care: Diverse applications within an integrated delivery system. eGEMS. 2014;2(1):1-8.

Sim JJ, Rutkowski MP, Selevan DC, Batcech M, Timmins R, Slezak J, Jacobsen SJ, Kanter MH. Kaiser Permanente Creating Safety Program: A mechanism to assure widespread detection and care for chronic kidney disease. Am J Med 2015; 128:1204-1211.

Graber ML, Trowbridge R, Myers JS, Umscheid CA, Strull W, Kanter MH. The next organizational challenge: Finding and addressing diagnostic error. Jt.Comm J Qual Patient Saf 2014;40(3):102-110.