NYC Health & Hospitals-Harlem

Development of a Thyroid Nodule Dashboard to coordinate and accelerate thyroid cancer screening at a municipal hospital

Project Lead: Rhonda Trousdale, MD 

Project AIM(s):

Aim 1: Develop a 2-part system that allows the Thyroid Team to follow patients who have been referred for thyroid ultrasound (US) and require follow-up evaluations to confirm or rule out a diagnosis of thyroid cancer. The 2-part system is a combination of EPIC Chat for rapid communication and use of a shared EPIC list of thyroid nodule patients.

Aim 2: Use the 2-part system to follow individual patients through the thyroid cancer screening process. Quantify the time from thyroid US to surgery for patients with thyroid cancer or suspected thyroid cancer. The goal is to promote rapid diagnosis of thyroid cancer and treatment.

Narrative description

Once a thyroid nodule is identified, the American Thyroid Association (ATA) has provided an algorithm for evaluating for cancer. Briefly, for patients without hyperthyroidism, thyroid US should be performed to measure the dimensions of the nodule(s) and specify any concerning characteristics of the nodule. If the nodule is over 1cm or the patient has a family history of thyroid cancer, or there is significant high- risk characteristics of the nodule, patients are referred for fine needle aspiration (FNA). In the United States this is usually an US- guided FNA. Based
on cytology, nodules are identified as high- risk, low- risk or indeterminate risk. If warranted, a nodule DNA sample can be sent for genetic testing to assist with classification. Based on nodule classification as well as other clinical factors, patients may undergo thyroidectomy to confirm if cancer is identified on surgical pathology. Thus, diagnosing cancer requires a coordinated effort between primary care physicians, endocrinologists, radiology, pathology, and surgery.

At the beginning of the project, the relevant departments involved in evaluation of thyroid nodules met to discuss their individual workflows to identify roadblocks in the overall thyroid nodule assessment workflow. The departments included: radiology for thyroid US and possible radioactive iodine therapy; endocrinology for hormone evaluation and coordination of patient care; interventional radiology for performance of FNA; pathology; surgery (primarily ENT); and IT for assistance with follow-up process creation. This cross-departmental team is referred to as the Thyroid Team.

Several issues were identified during the team meetings. First, the radiology department reported that during COVID they had stopped performing thyroid US because it was considered a “non-essential” procedure. This led to a large backlog of requests for thyroid US. When thyroid US was resumed, there was not enough staff to address the backlog in a timely manner and address the new orders coming in, so providers who commonly ordered thyroid US were notified to re-order the test the next time they saw the patient to ensure the team would contact the patient right away. This made the data from time to order to time of completion of US inaccurate. Another problem that was unknown to the team was a change in location for cytology processing. FNA specimens collected by the team at Harlem were packaged and sent to another NYC Health + Hospitals (NYC H+H) facility – Jacobi in the Bronx. Thus, monitoring the transport of samples and processing in another facility needed to be added to the evaluation. Furthermore, at Harlem when thyroid fine needle aspiration (FNA) samples are collected for cytology evaluation, there is also a tube collected for genetic testing. But genetic testing is only completed on indeterminate samples. Jacobi did not have a workflow for genetic processing. This Harlem genetic workflow needed to be created at Jacobi to ensure genetic samples were handled appropriately. Finally, there was personnel changes in the surgery department that effected communication.  

Ultimately development of an electronic dashboard was abandoned due to associated costs and resources, and instead the project team focused on readily available methods for improving team communication. We revised Aim 1 to use the internal communication system of the hospital EMR, Epic Chat, to improve communication between teams. The use of Epic Chat was critical for 2 reasons. First, Epic Chat is HIPPA protected. Chat allows for the patient of interest to be “pinned” to the message to avoid confusion about which patient is under evaluation. Second, it allows for multiple providers and administrators to be contacted simultaneously to ensure rapid team communication. The team identified the people who are most relevant to addressing the workflow so the most relevant stakeholders were included in the EPIC chat list. In addition to improving team communication, there was a need for a common patient list in the EMR that could be accessed by all Thyroid Team members to keep track of patients under evaluation. Epic has an excellent program for providers to create an individual list for inpatient review, but this did not exist for outpatients. The IT team at Harlem had adapted an inpatient list process for the Social Workers in the Outpatient Department. The Thyroid Team was able to customize the outpatient Social Worker program for identification of Thyroid patients undergoing outpatient evaluation. New clinicians continue to be onboarded to the follow-up process and program evaluation is ongoing.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Workflow (includes testing, follow-up, and referrals)
  • Health information sharing and accessibility via health IT

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)