Using an Automated Data-driven, EHR-Embedded Program for Mailing FIT kits: Lessons from the STOP CRC Pilot Study

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Abstract

Background

The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) study is collaboration among two research institutions and health-systems partners. The main study, scheduled to begin in 2014, will assess effectiveness of an intervention program using electronic health record (EHR) clinical decision support (CDS) tools to improve rates of colorectal-cancer screening in federally qualified health centers (FQHCs). Very few studies, and no large studies, aimed at raising CRC screening rates have utilized an EHR-embedded system.

Study design

We piloted the use of an EHR-embedded real-time patient registry reporting tool in a pilot study undertaken prior to beginning our main CRC screening study. The pilot study goal was to assess feasibility and effectiveness of two clinic-based approaches to raising rates of colorectal cancer screening among selected patients aged 50–74 who were not up-to-date with colorectal-cancer screening guidelines. We used work sessions and qualitative interviews with clinic personnel to assess performance of the tool, as well as to identify specific elements of the tool’s functionality needing refinement.

Results

Two critical elements of the EHR tool allowed us to mail FIT kits efficiently to appropriate patients: (1) having a direct interface with the laboratory that processed the FITs, thus allowing for real-time updates to the registry; and (2) being able to place lab orders from a list of selected patients. We identified the following elements that needed refining: the use of Health Maintenance (EHR function for tracking screening eligibility and due dates incorporating STOP CRC inclusion and exclusion criteria), and the development of report templates for identifying patients eligible for each step.

Conclusion

We found that most elements of our EHR-embedded program worked well and that specific refinement may improve the accuracy of identifying patients at each step. Our findings can inform future efforts to build EHR-embedded CDS tools for preventive services.

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Most cited references 15

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Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial.

Thomas D. Sequist, Robert Fletcher, John Ayanian … (2009)

Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas. Screening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%; P = .09). Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.

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An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial.

Jessica Chubak, Sally Vernon, Melissa L. Anderson … (2013)

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals. To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years. 4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047) 21 primary care medical centers. 4675 adults aged 50 to 73 years not current for CRC screening. Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2. The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2). Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]). Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability. Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.

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Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics.

Gary Longton, Ricardo Jiménez-Peydró, Gloria Coronado … (2011)

Hispanics in the United States are less likely than other groups to receive screening services for colorectal cancer. The authors conducted a clinic-based individual randomized trial that enrolled Hispanic patients ages 50 to 79 years who had been seen in the Seattle-based community clinic in the past 5 years. A total of 501 patients met the eligibility criteria and were randomized to 1 of 3 conditions: 1) usual care; 2) mailed fecal occult blood test (FOBT) card and instructions on how to complete the test (mailed FOBT only); and 3) mailed FOBT card and instructions on how to complete the test, telephone reminders, and home visits (mailed FOBT and outreach). The authors assessed postintervention differences in rates of FOBT screening in intervention and usual care groups using computerized medical records reviewed from June 2007 to March 2008. Data analysis occurred between November 2008 and September 2009. Nine-month postintervention screening rates were 26% among patients who received the mailed packet only intervention (P < .001 compared with usual care) and 31% in the group that received the mailed packet and outreach intervention (P < .001 compared with usual care). This compared with 2% in the group that received usual care. Screening rates in the mailed FOBT only group and in the mailed FOBT and outreach group were not significantly different (P = .28). Culturally appropriate clinic-based interventions may increase colorectal cancer screening among underserved Hispanics. Copyright © 2010 American Cancer Society.

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Author and article information

Journal

Journal ID (nlm-journal-id): 101632871

Journal ID (pubmed-jr-id): 42596

Journal ID (nlm-ta): J Gen Pract (Los Angel)

Journal ID (iso-abbrev): J Gen Pract (Los Angel)

Title: Journal of general practice (Los Angeles, Calif.)

ISSN (Electronic): 2329-9126

Publication date Nihms-submitted: 25 May 2014

Publication date (Electronic): 5 January 2014

Publication date PMC-release: 17 November 2014

Volume: 2

Electronic Location Identifier: 1000141

Affiliations

[1 ]Kaiser Permanente Center for Health Research, USA

[2 ]OCHIN, USA

[3 ]Virginia Garcia Memorial Health Center, USA

[4 ]Group Health Research Institute, USA

Author notes

[* ] Corresponding author: Gloria D. Coronado, 800 N. Interstate Ave, Portland, USA, Tel: (503) 335-2427; Gloria.d.coronado@ 123456kpchr.org

Article

Manuscript ID: NIHMS582684

DOI: 10.4172/2329-9126.1000141

PMC ID: 4233714

SO-VID: 460e20c6-8b0c-4dda-9356-0b3bb446a75f

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Using an Automated Data-driven, EHR-Embedded Program for Mailing FIT kits: Lessons from the STOP CRC Pilot Study

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Abstract

Background

Study design

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Conclusion

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Most cited references 15

Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial.

An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial.

Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics.

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