Opinion | Striking With the Right Care While the Iron Is Hot

Once we bring about change, how can we keep it going?

Recently, as part of a large hospital-wide population health initiative, we’ve been looking at certain key practice indicators and finding new ways to overcome deficits in recommended screenings among our patients.

One of these projects involves closing the gap in colon cancer screening among our patients.

When a patient has a colonoscopy done at our own GI practice, the procedure “satisfies” the colon cancer screening health maintenance item in the electronic health record.

If they do a colonoscopy with an outside gastroenterologist, and we get the report, and that report is scanned against the colonoscopy order in the system (and that’s a lot of “ifs”), it will likewise update the colon cancer screening field.

Or when they do a home-based test (such as Cologuard or FIT testing), this can also toggle the entry to indicate it has been completed.

As things stand, when patients have not completed recommended colon cancer screening in one form or another, providers are alerted with a “best practice alert” as well as a “gaps in care” alert within the electronic medical record (EMR).

Somehow, this just hasn’t seemed to move the needle on the dial that much.

I’ve written before about how things like large reports delivered to the practice that contain spreadsheets of patients needing a screening or other intervention don’t seem to be the way to actually get them done.

And often within the electronic medical record, these other alerts come up at a time when the provider is probably not in the room with the patient, not ready to put in an order, or not in a position to have a discussion with the patient about whether they want to proceed with said colon cancer screening.

We need to find a better way to strike while the iron is hot.

One pilot project we’re currently working on breaks up this list of patients into a smaller subset, focusing on a particular population, and targeting individual providers in the few days before a patient who needs this intervention have an imminent scheduled appointment in our practice.

To start with, you need a good numerator, knowing who is truly due for colon cancer screening and who may have already had one.

In a fairly labor-intensive fashion, the team working on this project gets a detailed report of those listed as due or overdue, and then targets those coming in the next few days.

But they do not only rely on the EMR data fields. They also cross-reference claims data on the patients to see whether they might have already had a colonoscopy, review the Media section of the EMR for a scan of an outside colonoscopy report, and conduct an in-depth chart review for any mentions of an outside procedure or a prior discussion where the patient declined ever wanting to get this done.

Armed with this information and the name of a patient who is truly in need of a colon cancer screening, a member of the project team reaches out to the individual provider through the chat function in our electronic medical record, right before the patient arrives for their appointment.

“Hey Dr. Pelzman, you have an appointment today/tomorrow with Mr. John Smith, and from our records and the review of his chart it looks like he is overdue for colon cancer screening.

Would you consider during your visit with him discussing what the options might be, and then our navigation team can help make sure that whatever he chooses gets completed?”

We are hoping the addition of this very personal reminder, along with the close proximity to the appointment, will help nudge things along and increase the rate of the provider at least having a discussion with the patient, an order being placed, and an update being made to the appropriate data fields.

Then, we hope, we can use the rest of the resources at our disposal to ensure things reach their desired and logical conclusion.

So, if we show this makes a difference, if this simple intervention gets a bunch of patients to get one of their healthcare maintenance items updated, how can we ensure the institution provides us with what we need to make this permanent and not just a pilot project?

Often when we do these sorts of projects, they come with short-term funding or people temporarily assigned to help out with a project.

Then to make things permanent, we need bigger studies and more data, along with a complicated business plan to convince people that this is the right thing to do.

Maybe it would be better if someone allowed those of us who are trying to do the right thing for our patients to just say this works, trust us, we know what we’re doing, the old way wasn’t working, and this new way does, please give us what we need.

Somewhere there’s got to be a budget for this; if not, what is the budget for?

If a practice and a group of providers say we need this for our patients, somebody somewhere should figure out how to make it happen.

Our patients need access to the screening services that make sure they stay healthy, they need access to massive amounts of mental health care resources in their communities, they need access to vaccines near home or work, they need access to food services and help with housing, they need access to Wi-Fi and broadband and Internet services and technical assistance so they can get telehealth and video visits the same as everybody else.

It’s true, some of these things may end up being costly, and at the end of the day the books may not end up being balanced.

But if we can prevent one case of colon cancer, prevent one delayed diagnosis of breast cancer, help our communities get the mental health they need, find ways to spread community resources to everybody equitably, then we’re doing things the right way, no matter what the cost.

Trust us.