Health information technology (HIT) optimization and the fight against colorectal cancer — Insights from Yale New Haven Health and Prisma Health

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To better understand how healthcare organizations are using technology to increase colorectal cancer (CRC) screening rates, Becker's Hospital Review recently spoke with two healthcare leaders from Yale New Haven Health's Northeast Medical Group in New Haven, Conn. — Maggie Shalagan, Population Health Manager, and Kaitlin May, Population Health Supervisor — and two leaders from Prisma Health Medical Group in Greenville, S.C. — Katie Lawrence, Executive Director, Ambulatory Optimization and Integration, and Molly Nichols, Manager, Performance Improvement.

To boost CRC screening rates, health information technology (HIT) optimization can play an essential role

When it comes to closing CRC screening gaps, health systems recognize electronic health record (EHR) systems have a central role to play. To find and activate patients for CRC screening, providers at Prisma Health Medical Group rely on data in patient medical records.

"We have a health maintenance tab in our EHR with all the care gaps that are coming due for a patient or that are overdue," Ms. Lawrence said. "Within primary care, the required documentation tab draws attention to things that will be due very soon. For colorectal cancer, physicians can see not only that patients are due for a screening, but the cadence of follow- up screenings that they need, based on clinical outcomes."

Yale New Haven Health's Northeast Medical Group also uses data analytics, population health dashboards and quality improvement dashboards in the EHR to track certain metrics. "Patients [aged] 45 to 75 are added to our colorectal cancer screening metric denominator," Ms. Shalagan said. "This populates the screening topic in the health maintenance section of the patient's medical chart."

HIT optimization also has a human element. Prisma Health Medical Group, for example, has created an Information Services Advisory Group designed to reduce EHR tasks for primary care physicians. "We realized we needed to use the medical record to the best of its ability," Ms. Lawrence said.

"The last thing we wanted was to add four clicks to every visit for every provider. The Information Services Advisory Group meets monthly and is co-led by a physician champion and a physician assistant champion. The team analyzes how to simplify care gaps and workflows by pre-populating forms and pre-launching screenings."

During office visits, care gaps are displayed to Prisma Health providers in a different color font and the associated orders are pre-checked. This saves a tremendous number of clicks for clinicians. "After we implemented changes like this in the EHR system, providers started coming up with other ideas and fed them to the committee," Ms. Lawrence noted.

Yale New Haven Health's Northeast Medical Group has also paired human resources with its EHR data to improve CRC screening rates. Preventive health coordinators, (PHCs), are embedded on-site in about half of the primary care practices.

"The PHCs work with clinicians and support staff in the office to review risk factors like personal and family history of colorectal cancer and other gastrointestinal (GI)-related issues that require a colonoscopy," Ms. Shalagan said. "Once they review that information, they engage in shared decision-making with patients and offer alternative screening methods like mt-sDNA tests, Fecal Immunochemical Tests, sigmoidoscopies and computed tomography (CT) scans of the colon."

Through their work in the EHR system, the PHCs have identified additional opportunities for system optimization. "A big problem that we had in our EHR was that colon cancer screening was automatically set at 10 years, but some patients need to be screened again sooner than that," Ms. May said. "Before we had the PHC role, there was no standardized process to change patient charts to reflect the correct recall. The PHCs began to enter the information into patient charts manually, but it was time-consuming and error prone. Now we are automatically changing screening recalls based on GI recommendations written in Epic®. This has improved the accuracy of patient reminders and it has streamlined work for the PHCs."

Health systems are turning to creative, tech- based solutions to remind eligible patients about CRC screenings

Patient engagement related to CRC screenings begins even before individuals visit the physician's office and continues both during and after office visits. Prisma Health Medical Group and Yale New Haven Health's Northeast Medical Group use a variety of outreach techniques at different points in the patient experience:

  • Branded text messaging and patient portals. Prisma Health Medical Group uses these techniques to communicate with patients about the need for CRC screening. Since around three-quarters of the organization's patient population uses the portal between visits, many patients find out about screening tests through this tool before they even have a doctor's appointment.

  • After-visit summaries, customized to each patient's orders. Prisma Health Medical Group utilizes this approach to inform patients about different options for CRC screening. "If a patient is due for their colonoscopy, they will receive information about the procedure in their summary," Ms. Lawrence said. "If they're disinclined to have a full colonoscopy and have no risk factors, they can use Exact Sciences mt-sDNA. Because we use mt-sDNA in all our markets, we've seen a huge uptick in our ability to meet colorectal cancer screening requirements. It's a lot less prep and it's easier to do in the comfort of the home. Our after-visit summaries include a link to a how-to video from Exact Sciences. It's nice for patients to review that and see what to expect when the box arrives at their door."

  • Phone calls and motivational interviewing. Between visits, the PHCs at Yale New Haven Health's Northeast Medical Group often reach out to patients via phone. "All of our PHCs are trained in motivational interviewing," Ms. May noted. "Instead of just telling patients that they're overdue for screenings, they can discuss the best option based on risk factors, personal preferences and other determinants. Once patients truly understand the issues, they can move forward."

  • Automated phone outreach with transfers to scheduling. Yale New Haven Health also utilizes automated telephonic outreach. When patients pick up the phone, an automated voice indicates that they are overdue for colorectal cancer screening and then patients can transfer to their primary care office to schedule a visit with their PCP to discuss screening options.

Provider visibility into CRC screening rates and patient choice of screening procedures are powerful ways to close care gaps

Prisma Health Medical Group works collaboratively with the lead physicians and administration at practices to ensure they understand screening metrics and their performance. "We do transparent comparisons of data across the organization which show how each practice stacks up. People know exactly where they and their peers stand. That has motivated people to see how they're doing," Ms. Lawrence said.

The provider scorecard pulls data from across the organization. "This is helpful for closing CRC screening gaps when the compliance piece of the measure has been done at an independent GI facility," Ms. Nichols noted. "Providers log into their scorecards once a month and they can pull gap lists from the scorecard. At any time, they can generate a comprehensive list and target individuals."

Prisma Health's provider scorecards are also helpful for the quality improvement team. As Ms. Nichols explained, "When we go into a practice, we look at the performance across all providers on a particular measure. If there is a wide amount of variance, that's usually due to workflow issues, so we analyze those first. If the providers' performance is within 5 percent to 10 percent of each other and they're underperforming, we need to understand what's not working across the practice."

Industry-level data can also be compelling for providers. "We work closely with Exact Sciences, and they've been great at sharing data to create change in our organization," Ms. May said. "They have data showing CRC screening compliance rates increase when patients are offered a choice, rather than simply being told that they must get a colonoscopy. Using data embedded in our EHR and shared data from Exact Sciences, we can show the difference in compliance rates to clinicians and staff within our primary care sites."

Targeted tech, magnified effect: CRC screening rates are rising thanks to technology optimization and innovative provider practices

Over the last 18 months, Prisma Health Medical Group has improved its overall colorectal cancer screening score by 5 percent. "That's a pretty big swing, given that we are less than a percent away from meeting the top decile national benchmark, not to mention the COVID-19 pandemic. We've tried to make progress by using many different levers, while simultaneously supporting providers and practices," Ms. Nichols said. "We're happy to see these outcomes."

Yale New Haven Health's Northeast Medical Group has found small changes and optimizations can lead to big shifts in terms of empowering patients and changing the culture from a clinician perspective. "When it comes to colorectal cancer, early detection really makes a difference in the diagnosis, quality of life and the patient's overall health state. By optimizing our EHR and our human resources, we are empowering patients to speak up on their own behalf and take care of their health. Although we believe the primary reference standard for CRC screening is the colonoscopy, clinicians understand that the best screening option is the one that gets done," Ms. Shalagan said. "We have to meet patients halfway and that's definitely made a difference."

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