Presentation
DH8 - Do EHRs Help or Hinder Coordination: Examining Facilitators and Barriers of EHR to CRC Screening Process
SessionPoster Session 2
DescriptionBackground:
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States (American Cancer Society, n.d.). CRC screening (CRCS) is a vital preventive measure that can reduce incidence and mortality through timely detection and intervention (DeGroff et al., 2018). Electronic health records (EHR) and patient portals, such as Epic’s MyChart, have the potential to streamline workflows and improve patient engagement in CRCS processes. However, there are still challenges in fully leveraging these tools.
The purpose of this study is to explore the facilitators and barriers associated with EHR use in CRCS by examining the experiences of both healthcare providers and patients, with the goal of identifying areas for improvement in clinical workflows and patient engagement.
Method
We conducted semi-structured interviews with both healthcare providers and patients. Our patient group consisted of individuals who had recently undergone CRCS at an academically affiliated network of FQHCs in the Midwest region of US.
After obtaining consent from participants, we used the Zoom platform to hold interviews
These interviews were recorded and later transcribed verbatim for analysis. All transcriptions were de-identified prior to analysis to ensure participant privacy. ATLAS.ti Version 23.2.1 was used to analyze the interviews (ATLAS.ti, 2023). We employed a mixed inductive-deductive coding approach, with two independent coders assigned to each transcript, ensuring all discrepancies were resolved through full consensus. The deductive coding was guided by Salas’s Heuristic Critical Considerations for Teamwork, commonly referred to as the “C’s of Teamwork” (Salas et al., 2014). The qualitative team then reviewed the codes to uncover emerging themes, focusing on identifying facilitators and barriers related to the use of EHR in the CRCS process.
Results
In this study, 25 semi-structured interviews were conducted with 9 clinicians and 16 patients aged 45 to 75 to explore current CRCS procedures, including the fecal immunochemical test (FIT) and colonoscopy, as well as to examine the effectiveness of EHR systems in supporting CRCS based on the experiences of both clinicians and patients. This report underlines the significant role of the EHR in supporting the screening process and points out specific challenges and areas for improvement. By analyzing participants' responses, we identified key themes regarding the use of EHR and patient portals in CRCS. The findings below outline the current facilitators and barriers to effectively using these systems in the screening process.
Current Facilitators
• Epic Chat: Clinicians found the Epic Chat feature helpful for real-time communication with medical assistants (MAs) and patient navigators, even when team members were not physically present. When discussing the CRCS process, one provider shared, “I would say with Epic, and being able to have the chat feature, so that even if the navigator isn't here, I can send a message, and the navigator can always respond.”.
• Alerts: Alerts in the health maintenance status module of some EHR systems serve as a key facilitator by reminding clinicians when patients are due for screenings. At the institution we studied, alerts in the EHR prompted providers to review or order necessary tests, such as a FIT test or colonoscopy, ensuring screenings were addressed during the visit (Patel et al., 2016). One clinician noted the value of these reminders: “Epic is nice, too, because I have a feature in my note that lets me know what health maintenance the patient is due for."
• Pending Orders in Epic: This feature in Epic contributes to the efficiency of the CRCS process by allowing clinical staff, such as medical assistants or navigators, to preemptively enter orders for tests like the FIT test or colonoscopy. These orders remain pending until reviewed and signed by the provider, ensuring that the screening process can proceed without unnecessary delays. As one clinician described, "If it seems that someone is potentially eligible for stool-based testing, they will let that patient know that they will pend orders on the visit, so that when providers show up and see the patient within the EMR, there's already a pended stool test.”.
• MyChart: Many patients find the MyChart patient portal to be a useful tool for accessing results and communicating with their healthcare providers regarding CRCS. Patients often receive important messages through the portal, facilitating efficient communication. One patient said, “They always tell me that I can have, you know, any results on MyChart,” demonstrating how they used the platform to check test results. Another patient mentioned how they used MyChart messages to communicate with their provider: “I sent her a message and she called me back to get my appointment on Monday”.
Barriers/Issues
• Digital health literacy: Digital health literacy presents a barrier to effective CRCS, as it impacts how patients access their results and communicate with providers using tools like MyChart. Patients with limited digital skills may struggle to retrieve important information or engage in timely follow-up. One patient shared, “when I went to my next appointment, I asked the doctor about the results,” instead of using MyChart to access or communicate about their screening results. This reliance on in-person visits reflects the difficulties some patients face in utilizing the platform, indicating there is not a “one size fits all” approach to patient-facing digital health for CRCS.
• Lack of Customization: Clinicians expressed concerns that while EHR alerts and reminders are helpful, they are not always customized to account for individual factors, such as a patient’s family history or specific risk factors. One clinician pointed out, "The patient history, including family history, is located within the record, but why is this not a flag or data used in a clinical decision support tool? Seems like a missed opportunity to use the record to promote more risk-concordant screening." Another clinician stated, "That might be variable by physicians, and…how their notes and things are set up,” suggesting that system customization is inconsistent across providers.
• Interoperability: Another challenge in the CRCS process is the lack of interoperability between health systems’ EHRs. One clinician shared that he had to cancel many FIT tests pended by navigators because patients had already completed screenings elsewhere, but the information was not accessible due to different EHR systems. The clinician explained, “So, in our community a lot of the patients have had a colonoscopy, and she just wasn't aware of it or couldn't access it in the chart, because it's in a different system that doesn't use EPIC.”
• Use of After-Visit Summaries: Some clinicians reported that MAs frequently don’t read after-visit summaries (AVS) which often contain instructions to provide patients with FIT tests at check-out, leading to missed screenings. When asked what could be improved, one provider said, "I would really like it if the MAs would read what's in the AVS and actually give people the FIT test." Another clinician added, "some of the people are still thinking, ‘if it wasn't told to me verbally, then it's not a thing’, even though it's right there in the chart.”
Discussion
Our study offers valuable insights for healthcare providers, clinical informaticians, and researchers by illustrating both the potential and limitations of EHR systems in supporting CRCS. While features like real-time communication and automated reminders can streamline workflows and improve screening efficiency, challenges such as limited system customization and low digital health literacy hinder the full utilization of these tools. Addressing these barriers through enhanced system design and targeted patient education could lead to better CRCS outcomes. Improved integration and personalization of alerts may further support efforts to increase screening rates and enhance patient care.
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States (American Cancer Society, n.d.). CRC screening (CRCS) is a vital preventive measure that can reduce incidence and mortality through timely detection and intervention (DeGroff et al., 2018). Electronic health records (EHR) and patient portals, such as Epic’s MyChart, have the potential to streamline workflows and improve patient engagement in CRCS processes. However, there are still challenges in fully leveraging these tools.
The purpose of this study is to explore the facilitators and barriers associated with EHR use in CRCS by examining the experiences of both healthcare providers and patients, with the goal of identifying areas for improvement in clinical workflows and patient engagement.
Method
We conducted semi-structured interviews with both healthcare providers and patients. Our patient group consisted of individuals who had recently undergone CRCS at an academically affiliated network of FQHCs in the Midwest region of US.
After obtaining consent from participants, we used the Zoom platform to hold interviews
These interviews were recorded and later transcribed verbatim for analysis. All transcriptions were de-identified prior to analysis to ensure participant privacy. ATLAS.ti Version 23.2.1 was used to analyze the interviews (ATLAS.ti, 2023). We employed a mixed inductive-deductive coding approach, with two independent coders assigned to each transcript, ensuring all discrepancies were resolved through full consensus. The deductive coding was guided by Salas’s Heuristic Critical Considerations for Teamwork, commonly referred to as the “C’s of Teamwork” (Salas et al., 2014). The qualitative team then reviewed the codes to uncover emerging themes, focusing on identifying facilitators and barriers related to the use of EHR in the CRCS process.
Results
In this study, 25 semi-structured interviews were conducted with 9 clinicians and 16 patients aged 45 to 75 to explore current CRCS procedures, including the fecal immunochemical test (FIT) and colonoscopy, as well as to examine the effectiveness of EHR systems in supporting CRCS based on the experiences of both clinicians and patients. This report underlines the significant role of the EHR in supporting the screening process and points out specific challenges and areas for improvement. By analyzing participants' responses, we identified key themes regarding the use of EHR and patient portals in CRCS. The findings below outline the current facilitators and barriers to effectively using these systems in the screening process.
Current Facilitators
• Epic Chat: Clinicians found the Epic Chat feature helpful for real-time communication with medical assistants (MAs) and patient navigators, even when team members were not physically present. When discussing the CRCS process, one provider shared, “I would say with Epic, and being able to have the chat feature, so that even if the navigator isn't here, I can send a message, and the navigator can always respond.”.
• Alerts: Alerts in the health maintenance status module of some EHR systems serve as a key facilitator by reminding clinicians when patients are due for screenings. At the institution we studied, alerts in the EHR prompted providers to review or order necessary tests, such as a FIT test or colonoscopy, ensuring screenings were addressed during the visit (Patel et al., 2016). One clinician noted the value of these reminders: “Epic is nice, too, because I have a feature in my note that lets me know what health maintenance the patient is due for."
• Pending Orders in Epic: This feature in Epic contributes to the efficiency of the CRCS process by allowing clinical staff, such as medical assistants or navigators, to preemptively enter orders for tests like the FIT test or colonoscopy. These orders remain pending until reviewed and signed by the provider, ensuring that the screening process can proceed without unnecessary delays. As one clinician described, "If it seems that someone is potentially eligible for stool-based testing, they will let that patient know that they will pend orders on the visit, so that when providers show up and see the patient within the EMR, there's already a pended stool test.”.
• MyChart: Many patients find the MyChart patient portal to be a useful tool for accessing results and communicating with their healthcare providers regarding CRCS. Patients often receive important messages through the portal, facilitating efficient communication. One patient said, “They always tell me that I can have, you know, any results on MyChart,” demonstrating how they used the platform to check test results. Another patient mentioned how they used MyChart messages to communicate with their provider: “I sent her a message and she called me back to get my appointment on Monday”.
Barriers/Issues
• Digital health literacy: Digital health literacy presents a barrier to effective CRCS, as it impacts how patients access their results and communicate with providers using tools like MyChart. Patients with limited digital skills may struggle to retrieve important information or engage in timely follow-up. One patient shared, “when I went to my next appointment, I asked the doctor about the results,” instead of using MyChart to access or communicate about their screening results. This reliance on in-person visits reflects the difficulties some patients face in utilizing the platform, indicating there is not a “one size fits all” approach to patient-facing digital health for CRCS.
• Lack of Customization: Clinicians expressed concerns that while EHR alerts and reminders are helpful, they are not always customized to account for individual factors, such as a patient’s family history or specific risk factors. One clinician pointed out, "The patient history, including family history, is located within the record, but why is this not a flag or data used in a clinical decision support tool? Seems like a missed opportunity to use the record to promote more risk-concordant screening." Another clinician stated, "That might be variable by physicians, and…how their notes and things are set up,” suggesting that system customization is inconsistent across providers.
• Interoperability: Another challenge in the CRCS process is the lack of interoperability between health systems’ EHRs. One clinician shared that he had to cancel many FIT tests pended by navigators because patients had already completed screenings elsewhere, but the information was not accessible due to different EHR systems. The clinician explained, “So, in our community a lot of the patients have had a colonoscopy, and she just wasn't aware of it or couldn't access it in the chart, because it's in a different system that doesn't use EPIC.”
• Use of After-Visit Summaries: Some clinicians reported that MAs frequently don’t read after-visit summaries (AVS) which often contain instructions to provide patients with FIT tests at check-out, leading to missed screenings. When asked what could be improved, one provider said, "I would really like it if the MAs would read what's in the AVS and actually give people the FIT test." Another clinician added, "some of the people are still thinking, ‘if it wasn't told to me verbally, then it's not a thing’, even though it's right there in the chart.”
Discussion
Our study offers valuable insights for healthcare providers, clinical informaticians, and researchers by illustrating both the potential and limitations of EHR systems in supporting CRCS. While features like real-time communication and automated reminders can streamline workflows and improve screening efficiency, challenges such as limited system customization and low digital health literacy hinder the full utilization of these tools. Addressing these barriers through enhanced system design and targeted patient education could lead to better CRCS outcomes. Improved integration and personalization of alerts may further support efforts to increase screening rates and enhance patient care.
Authors
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer