We evaluated referrals for 367 patients diagnosed with CRC over a 6-year period to determine if the timeliness of diagnostic colonoscopy was associated with the quality and quantity of information transmitted via the CPOE-generated referral request. Our findings suggest that in a system with limited endoscopic capacity, both quality and quantity of information transmitted to the consultant affected the wait time between referral and colonoscopy. Shorter wait times were associated with referral requests that documented three diagnostic clues versus one clue, originated in the inpatient setting, were marked as urgent or next available (versus routine), and documented a verbal discussion with a consultant. Clues such as iron deficiency anemia, abnormal CT scan or barium enema, suspected mass on physical examination, abdominal pain, and obstruction were significantly associated with wait times of <60 days. Conversely, other clues such as positive FOBT, hematochezia, and history of polyps were associated with >60 day wait times. Longer wait times were also more likely for referrals that requested colonoscopy for “screening” despite the presence of other diagnostic clues.
The use of CPOE-generated referrals has potential for overcoming several types of communication failures between the PCP and specialist. Breakdowns in referral communication due to inadequate or absent information transmission have been previously described in health care systems without CPOE-generated referral requests.10,18–20
In one study from Brigham and Women's Hospital in Boston prior to use of computerized referral requests, almost 68% of specialists reported not receiving any information from the PCP prior to the referral visit.18
Other studies have described communication breakdowns where the consultant and the PCP do not agree for the reason for referral.21
An added benefit of using CPOE is provision of templates or checkboxes to the referring physician when requesting a colonoscopy. This information can potentially be used to generate a likelihood score for CRC from an evidence-based algorithm, which can rationally inform colonoscopy scheduling.
We found that several diagnostic clues were associated with shorter wait times to diagnostic colonoscopy, suggesting the presence of some prioritization mechanism to schedule procedures. However, seemingly logical prioritization strategies may not be supported by current evidence. For example, a recent meta-analysis concluded that most “alarm” features such as anemia, change in bowel habits, and weight loss have poor sensitivity and specificity for the diagnosis of CRC.22
Shorter wait times for referrals documenting obstruction and abdominal pain occurred because the majority (74.3%) of these were emergent inpatient referrals. Additionally, clues suggesting the presence of a tumor, such as abnormal imaging or mass, were associated with short wait times. Contrary to what we expected, clues that signified bleeding, such as positive FOBT and hematochezia, were associated with a greater than 60 day wait time.
Consistent with previous literature, we found patient non-adherence to play a significant role in timeliness of diagnostic colonoscopy procedures.3,23,24
Our findings underscore the need for future efforts to improve adherence to diagnostic colonoscopies. This is especially important in systems with constrained endoscopic capacity, where there may be lengthy delays before procedures can be rescheduled. Most of the work on improving patient adherence is mostly focused on screening colonoscopy25,26
and could potentially be applied to diagnostic procedures, where the yield of the procedure is expected to be higher.
Our findings suggest that timeliness may relate to “how you ask” through CPOE.27
For instance, we observed longer wait times when providers inappropriately listed “screening” as the reason for the diagnostic colonoscopy despite the presence of other diagnostic clues in the patient’s record. Similarly, using an unqualified diagnosis of “anemia” was associated with a longer lag time than when “iron deficiency anemia” was used. Consultants may find it cumbersome to perform additional chart reviews to look for clues other than those provided in the referral request. Thus, effective electronic communication using CPOE requires providers to receive proper training on how best to use referral templates. Obligatory fields in referral templates may also help but do not guarantee the accuracy of information. Work on use and acceptability of templates for gastroenterology referrals at this institution is ongoing. Future research, preferably using prospective studies, is also needed to confirm our findings in other health care systems that use CPOE.
According to a recent Cochrane review, interventions to improve outpatient referrals from primary care to secondary care are needed, and only a limited number of rigorous evaluations exist to inform policy.28
To our knowledge, this is the first study that evaluates how characteristics of CPOE-generated referral content affect the timeliness of referral completion. Our study involved several satellite clinics, a large study sample, and a large number of referring providers. Providers in the VA are trained and well versed with CPOE, which has been used in most VA facilities since before 2002.
Our study had several limitations. The study population included only patients who were eventually diagnosed with CRC. Therefore, the findings may not apply to the vast majority of requests for colonoscopy in which CRC is not found, and any selection bias resulting from our methods is difficult to detect. Additionally, the study population (predominantly male veterans), and the VA setting may make our findings less generalizable to other practices, especially those that do not use electronic referrals. We also did not collect data on clinical outcomes related to delays in CRC diagnosis. Previous studies of the association between diagnostic delays and CRC outcomes have yielded conflicting results.29–31
Although the precise definition of a meaningful delay is unclear, delays in care are relevant facets of patient safety and satisfaction.
In conclusion, we found several referral characteristics were associated with lag times for diagnostic colonoscopy in CRC patients, including the type as well as frequency of diagnostic clues provided to the consultants (more than one clue is better than one or no clues), flagging of urgency, and documenting verbal discussions with consultants to expedite referrals. In systems with limited endoscopic capacity, attention to these aspects of diagnostic information transmitted through CPOE based referrals may help reduce delays in CRC diagnosis.