In a cohort of average-risk adults, electronic outreach via an integrated personal health record produced an initial increase in colorectal cancer screening rates, but this effect was not sustained. Only half of patients in the intervention group viewed the electronic messages despite having it sent from their personal physician, which limited the overall effectiveness of the intervention. Users of the web-based risk assessment tool represented a small and generally low risk subset of all eligible patients, however they responded favorably to the tool and more often requested and received colorectal cancer screening exams than patients who were invited to use the tool but did not do so.
Increased screening is essential to reduce the incidence, morbidity, and mortality of colorectal cancer.17
Informed decision making and education can motivate patients to pursue appropriate screening.18-21
However, primary care physicians face increasing pressures to provide a wide range of preventive counseling during increasingly shorter office visits.22
Colorectal cancer screening presents a particular challenge given the multiple screening options, and many patients do not receive adequate counseling for colorectal cancer screening. 10, 23
Prior research has suggested that patient-directed interventions including videotaped decision aids,24
educational mailings,12, 25, 26
and nurse counseling27
can increase colorectal cancer screening rates. Even in the presence of such programs many patients remain unscreened, and such programs can have substantial costs.23, 28
Personal health records offer the promise of engaging patients in a more efficient and interactive manner.14, 29, 30
Patients have expressed interest in interacting with their medical record using electronic portals similar to the one used in our intervention.31
However, rigorous evaluations of targeted uses of such systems to improve care have been limited in number and had mixed results.15
One pilot study of an e-mail outreach program failed to increase colorectal cancer screening rates, but only 25% of patients viewed the messages.32
In another study within a large health maintenance organization, electronic messages delivered within an integrated personal health record found that two-thirds of patients viewed the message, and colorectal cancer screening rates were improved at 3 months.33
Our study builds on this prior work in important ways. First, about half (54%) of patients in our study viewed the personalized electronic messages, a rate that was intermediate relative to these two prior studies of personalized messages.32, 33
One of the significant challenges to the effective use of personal health records to improve quality of care is not only to increase their adoption by physician practices, but also to ensure effective use by patients.34
The solutions to this issue may be straightforward, such as ensuring accurate email addresses; or more complex, such as ensuring that the information and services provided by the personal health record meet the needs of patients. Our study highlights that while personal health records are often promoted to improve quality of care, it is important to evaluate such systems to ensure they are implemented in a manner that achieves this goal.
Second, we demonstrated a promising initial increase in screening, similar to a prior study,33
however we found that this effect was not sustained longer term. This may have been due to the effects of prior programs in our system to promote colorectal cancer screening, including annual paper mailings to adult patients overdue for colorectal cancer screening.12
Future work should focus on the impact of quarterly or semi-annual electronic outreach to patients on their screening rates, and how such regular outreach is received by patients. Third, the baseline screening rate in our population was very high (82%); exceeding that in a successful prior study of electronic patient outreach (69%),33
leaving an unscreened population of patients who may have been much more resistant to screening. As colorectal cancer screening rates rise across the country,9
it is increasingly important to understand how to promote screening in this remaining unscreened group.
Finally, we incorporated a link to a web-based risk tool to further personalize the information regarding colorectal cancer screening as many high-risk patients are not screened appropriately.35
Most patients report having the greatest trust in health information received from their physician, but many turn to the Internet for convenience, particularly for cancer-related information.36, 37
We employed a model that combined the trust of a recommended information source from the physician's office with the convenience of an Internet-based tool. We chose one validated web-based risk tool that was available when our study was implemented, and other options including the National Cancer Institute Colorectal Cancer Risk Assessment Tool can also be used to provide patients with risk information.38, 39
Those who accessed the tool in our study found it helpful and often sought screening afterward, but only a small proportion of patients used the tool. While providing accurate information in an easily interpretable format should remain essential goals of Internet-based tools,40, 41
future work also needs to focus on how to engage patients in using such tools when recommended by their physicians.
Our study findings should be considered in the context of some limitations. First, we relied on physicians to approve the inclusion of their patients in the study, and their approval was not obtained for 40% of eligible patients. This factor represents an important consideration for future work involving this type of direct patient outreach focused on quality improvement. Involvement of physicians prior to such patient outreach can provide an important safety screen, however it can also represent a barrier to quality improvement, particularly if physicians do not respond to requests to enroll their patients.
We do not have long-term follow up of patients regarding colorectal cancer outcomes, nor do we have information regarding patient perceptions of receiving electronic messages or of using the online risk assessment tool. The risk assessment tool we used provided level of risk relative to other age-matched peers, and therefore may have downplayed the steadily increasing risk of developing colorectal cancer after age 50.
Finally, some issues may limit the generalizability of our study findings to other settings and patient populations. The organization we studied has a history of focusing on colorectal cancer screening,12
and it has already achieved a relatively high rate of colorectal cancer screening. Also, patients actively using personal health records, such as those enrolled in our trial, may differ from the broader population according to race, ethnicity or socioeconomic status,42
as well as in their enthusiasm and comfort with using web-based applications. In the large medical group we studied, approximately 18% of patients ages 50 to 75 years old were active users of the personal health record in late 2009. Future research will be needed to understand how our results extend to other settings.
In conclusion, this randomized trial of electronic messages to patients within an integrated personal health record demonstrated an initial increase in the rate of colorectal cancer screening that was not sustained over time. However, only about half of eligible patients viewed the electronic message, and fewer than 10% accessed the web-based risk tool. Further research is needed to understand the most effective ways for patients to use interactive health information technology to improve their care and reduce the morbidity and mortality of colorectal cancer.