Can EHR prompts improve cancer screening rates?

By Abraham Kim, staff writer

November 15, 2019 -- Programming the hospital electronic health record (EHR) system to notify clinicians if and when patients are due for breast or colorectal cancer screening exams increased the exam ordering rate, but not the screening completion rate, in a new study published online November 15 in JAMA Network Open.

The researchers, led by Dr. Esther Hsiang from the University of Pennsylvania School of Medicine, developed an automated prompt, or a "nudge," that requires medical assistants to accept or decline an order for breast or colorectal cancer screening when meeting with patients who fit eligibility requirements.

They implemented their EHR prompt at three hospitals within the Penn Medicine health network from September 2014 to August 2017 to support the preliminary screening process. Currently, primary care physicians need to perform manual checks of each patient's medical records to determine whether the patient is eligible for certain cancer screening exams.

"Clinicians are increasingly being asked to do more with a fixed amount of time with a patient," Hsiang said in a university statement. "By directing the intervention to medical assistants, this reduced the burden on busy clinicians to respond to alerts and instead gave them more time to have a discussion with their patients about screening."

Among 26,269 women, the rate of mammography screening exams ordered increased by an average of 22.2 percentage points at hospitals using the EHR prompt, compared with hospitals that did not employ the prompt. For the 43,647 patients eligible for colorectal cancer screening, order rates increased by an average of 14 percentage points.

Effect of implementing an electronic health record prompt for cancer screening
  No intervention EHR prompt
2014 2015 2016 2014 2015 2016
Breast cancer screening
Screening exam order rate* 53.5% 61.4% 59.2% 59.1% 68.8% 87.5%
Screening completion rate 24.1% 31% 34.8% 36% 40.8% 45.9%
Colorectal cancer screening
Screening exam order rate* 32.1% 49% 50% 51.4% 65.2% 82%
Screening completion rate 23.1% 27.6% 27.7% 32.8% 40.4% 39.7%
*The differences were statistically significant (p < 0.001).

However, the substantial increase in the proportion of breast and colorectal cancer screening exams ordered only led to small gains in the rate of completed screening exams, which did not reach statistical significance.

The completion rates for breast and colorectal cancer screening exams might not have increased alongside the order rates due to issues with scheduling and complying with steps for screening preparation, the authors noted. In the case of colorectal cancer screening, participants often have to undergo a lengthy process before receiving screening exams such as a colonoscopy, lowering their motivation to participate.

"Cancer screening involves both the clinician recommending and ordering it as well as the patient taking action to schedule and complete it," senior author Dr. Mitesh Patel said. "Our study found nudges can be very influential, but for cancer screening, they likely need to be directed to both clinicians and patients."

Acknowledging this challenge, Hsiang and colleagues are working on implementing a way to prompt both the clinician and the patient regarding screening exams for a variety of diseases beyond breast and colorectal cancer.

"Since EHRs are used by more than 90% of physicians, this is a really scalable approach," Patel said. "It is likely that it could be successful for other types of screening."

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