Editor's Pick: Digital Health Safety Surveillance: "Improving Patient Support Throughout the Diagnostic Trajectory" ft. Sungmin Woo, MD, PhD
UCSF CODEX connected with Sungmin Woo, MD, PhD, associate professor in the Department of Radiology at the NYU Grossman School of Medicine, for his insights on a recent study on digital health safety surveillance and improving patient support throughout the diagnostic trajectory.
Moran B, Weon JL, Hinshelwood M, et al. Digital Health Safety Surveillance: Improving Patient Support Throughout the Diagnostic Trajectory. Jt Comm J Qual Patient Saf. 2026;52(7):267-275. doi:10.1016/j.jcjq.2026.04.004
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Q&A Video ft. Sungmin Woo, MD, PhD
Watch the full Q&A here.
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(Note: The responses below are highlights from the Q&A video above.)
What's the point?
Before we dive into the actual results and specifics of the study itself, I do want to give a little bit of background. As a radiologist myself, we've always been focusing on how to improve diagnostic excellence or decrease errors. And mainly that's been to improve the accuracy of a certain test, or to make it better so that it doesn't miss a result or a diagnosis.
But there's been a pivotal shift in recent years, and the scope of diagnostic excellence is expanding. And it's not only about getting the right test or have the right result. You want to make sure that the abnormal test results translate into an impactful, you know, healthcare result for the patients. So, you don't want any missed or delayed follow-ups on that abnormal test result.
This study actually focuses on that component of diagnostic excellence or diagnostic errors. With that background in mind, this study was in a large institution, and they talk about their experience in establishing and expanding this safety net surveillance program in response to a Sentinel event, or an event they had, which was actually related to a missed opportunity for an abnormal imaging result that resulted in a poor outcome for the patient. They actually address that problem by systematically establishing a sort of automated, tech-heavy, digitized program, which also involves a task force-like team that includes virtual care providers, social workers, and especially trained nurses--all embedded and integrated within the health system and the electronic health records. They try to tackle how they can address these missed or delayed imaging results, in terms of their follow-ups.
They also expanded to many different high-risk clinical scenarios, which included, for example, if you have a new cancer diagnosis, but you don't have an oncologist follow-up, or you have an elevated tumor marker, but you don't have a specialist follow-up to really work that up. They found that this was feasible, and they were able to really, really address that problem--those missed and delayed follow-ups on abnormal test results.
The core takeaway is that it was a centralized, tech-enabled safety net system that was integrated into the health system, and it dramatically closed care gaps. Two particular key results do come to mind when talking about this paper. We talked about delayed imaging follow-up for that test result, right? The completion rates for following up on that jumped from, at baseline, around 40% up to nearly 97%. That's close to 100% after the full implementation of this safety net surveillance program. And when you look at a certain subgroup within those patients, what they found was around 4% of those led to an actual early cancer diagnosis, and another over 3% were findings that required immediate surgery. This isn't a big number, but if you think about it, it's not small at all, either. And these outcomes are very tangible, impactful, and very likely saved lives.
Overall, it's a very interesting study with very interesting data. Hopefully, it will impact how we address missed and delayed follow-ups for abnormal test results.
Why does this matter?
We’ve mentioned the implications this has, why it's important, and why it matters, but I do want to delve into a few more aspects that particularly catch my attention. One is that this paper highlights a shift in how we look at diagnostic excellence.
To put this into context, traditionally, it's been more reactive and at the individual level. For example, all these busy clinicians and providers are responsible for ensuring that patients with abnormal test results receive follow-ups. It must be communicated; they had to get in contact and make sure the patients get referred to the specialist, and so on. But it relies on the individual level; sometimes it falls through the cracks, and we have to respond reactively.
However, bringing this into a more centralized, digitized safety-net surveillance network or program makes the process more proactive rather than merely reliant on the individual provider. This becomes a more systemic approach. With this kind of automated, overarching, systemic approach, you are less likely to have patients fall through the cracks when they receive an abnormal test result. So we're being more proactive in how we care for patients.
Second, this touches on the health equity aspect of diagnostic safety and accuracy. It’s been pretty well established that diagnostic errors disproportionately affect and cause more harm to vulnerable, under-resourced, and minority populations. What this program did was not only set up this really excellent safety-net surveillance program, but also establish a task force of virtual care providers, social workers, and specially trained nurses who were bilingual in Spanish and English. Together, they were able to address not only language but also other obstacles that make it difficult for the patient to receive follow-up care, such as transportation and childcare.
Additionally, when they looked at the patient population, about half of the patients were Spanish-speaking. But more importantly, when they looked at the geographic distribution of patients, they found that a large proportion lived in neighborhoods considered socially and economically vulnerable.
To bring this back together, many aspects of this paper have implications for diagnostic excellence. One is the shift from a more reactive type of traditional care to a more proactive surveillance. And another is that it also touches on an important issue of health equity within the diagnostic safety issue.
Who does this impact?
Health system level/health system leaders/QI professionals: Now, this study is basically anecdotal evidence of how this kind of safety and surveillance program can actually work within a system, how they responded to a sentinel event, and made it even better. So this provides a blueprint for others to benchmark. While different systems have different pros and cons and structural differences, the main takeaway is that this is feasible and cost-effective. For each episode of taking care of these incidents, the cost rounds up to about $65, and it's scalable. They started it off with dealing with missed or delayed follow-up on abnormal immunity test results, but they expanded to things like tumor markers that were abnormal that didn't have specialist follow-up, or a new cancer diagnosis without an oncology follow-up. They were able to scale this up into other kinds of very important but high-risk clinical scenarios.
Clinicians: This doesn’t take away the responsibility from each individual provider to ensure that their patients with abnormal test results receive a follow-up. But with this, they share that burden with the centralized safety net system. So, this offers a little relief from that burden, and because of that, the clinicians are able to provide a higher level of care and touch on things they might not otherwise have the opportunity to.
Patients: Patients will receive better care and potentially improve their healthcare outcomes. But if you look at it from another perspective, it transforms patients from passive recipients of health data on electronic health portals to more integrated participants in the active healthcare network. So, this would ensure that every individual--regardless of their background, language, or social climate status--will get guided safely through their full diagnostic journey, or as the title says, throughout their entire diagnostic trajectory.
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About Editor's Picks
Curated by the UCSF CODEX team, each Editor’s Pick features a standout study or article that moves the conversation on diagnostic excellence forward. These pieces offer meaningful, patient-centered insights, use innovative approaches, and speak to the needs of patients, clinicians, researchers, and decision-makers alike. All are selected from respected journals or outlets for their rigor and real-world relevance.
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