Challenges to effective CRC screening and follow-up persist at three benchmark institutions for health IT. Each of our study sites relied on CDS (computerized or paper reminders, or an electronic template), coordinated with an EHR. Our results showed challenges to CRC screening and follow-up at all stages of the process, including screening, receiving laboratory results, and following up with the patient. We describe our findings in this context.
Challenges to Effective CRC Screening
The first point in the process, where the CRC screening recommendation is made, was problematic in several ways. The design of the EHR and CDS was a barrier to effective CRC screening recommendations when the CDS (i.e., the clinical reminders for CRC screening) were not accurate for the patient, and/or when the usability of the computer tools was poor (e.g., not having the appropriate options in the dialog box for the provider to accurately satisfy the clinical reminder). Also, CRC screening was not performed in some cases when providers faced high time pressure and/or when they perceived that the patient had more serious problems that needed attention (i.e., acute vs. preventive services). Staff-related compliance issues in the process were also identified at this point, such as distribution of FOBT cards to the patient.
Challenges to Effective Flow of CRC Laboratory Results to Primary Care Provider
Another major hurdle in the process from the primary care providers’ perspective was receiving results from the colonoscopy exam or other CRC screening tests. Challenges in receiving and documenting results from colonoscopy exams performed “outside” of the institution were reported at all study sites. Often, the patients were responsible for relaying this information to their primary care provider; however, reliance on patient memory was a barrier in this instance, especially in cases where the exam took place several years prior. Coordination with the commonly-used GI service, internal to the institution, was also reported as a challenge, such as delays in receiving results. Although not reported as a common barrier across sites, an EHR at one site that used a blend of paper charting posed a challenge to some providers in knowing where to find the most current CRC screening results, as some providers relied on paper charting and others relied on computerized charting.
Challenges to Effective Patient Follow-up
Finally, after receiving the results, the primary care providers reported challenges in following up with the patient in some cases. Again, “outside” exam results was a barrier. Challenges in receiving and documenting results from colonoscopy exams performed “outside” of the institution were reported at all study sites. However, when these results were documented and available to the primary care provider, there were sometimes problems with patient follow-up. For example, the report from the “outside” colonoscopy exam did not always include recommended actions.
We collected qualitative data at three benchmark institutions for HIT, VHA, RI, and PHS, to understand provider perspectives on challenges to effective CRC screening and follow-up, as related to the EHR and CDS systems. Although these institutions have varying forms of EHRs and CDS, our preliminary, ongoing analysis revealed common barriers, spanning CRC screening, receiving laboratory results, and following up with the patient. These challenges to effective CRC screening suggest that design enhancements can be made to the HIT, such as improved usability and integration into workflow, to reduce or eliminate some of these challenges and better support the primary care providers and clinic staff. Further study is needed to examine applicability of these results to institutions with less experience in CDS.