How to d e s i g n and r e f i n e effective EMR tools for CRC screening Gloria D. Coronado, PhD Beverly Green, MD, MPH

Technological advances

Original thinking Revised thinking How to design EMR tools… Engage clinic staff Select specifi- cations Prototype tools Test tools Train teams Refine tools Design tools Use tools

Key messages  How to build effective EMR tools:  Assemble your team;  Identify goals – save time, accurately identify patients, improve rates, avoid unintended consequences – choose specifications;  Consider workflows and data sources  Anticipate unintended consequences  Train, re-train  Revise workflows and tools  PDSA  EMR work sessions

Assemble your team  Leadership buy-in  Clinical staff (providers, MAs, front desk staff, etc.)  Quality improvement leads for testing  Training, and re-training

Select design specifications  What is important?  What is possible?  Review what others have done  Real-time data  Sustainability and long-term use  Rely on Health Maintenance and STOP CRC codes  Over time can rely only on Health Maintenance  Automate as much as possible  Design could be used across EMR platforms PossibleImportant

Consider unintended consequences RiskExample Patient careSelecting ineligible patients, choosing a FIT kit with poor performance characteristics, poor lab interface Reputation (with patients and peers) Selecting ineligible patients, personalize letters Financial risks (cost vs. reimbursements / incentives) In-house vs. outside processing Patient experience with careAppreciation vs. confusion (billing) Data integrityMis-coding, impact on reporting requirements/ incentives Relationships with peersLab interface

Original thinkingRevised thinking Think about workflows and data sources…

Clinic workflows Identify patient Pre-visit chart review Office visit Gaps in care report Provide test In-person during visit Mail Encounter type Visit encounter Lab encounter Interim note Order type FutureRegular Order class External interface, outside collection External interface Back office Where processed Clinic lab Outside lab How documented Result note Problem list, free text Problem list, coded terms HM Understanding variations in fecal testing by clinic

Step-wise exclusions Step 1: Mail Introductory letter Step 2: Mail FIT kit Step 3: Mail Reminder Postcard EMR tools in Reporting Workbench, driven by Health Maintenance; Step-wise exclusions for: Invalid address Self-reported prior screening Completion of CRC screening

Key design features Front- end tools Back- end data Real-time lists of patients eligible for each intervention step; Inclusion / exclusion codes and Health Maintenance (may rely solely on Health Maintenance, if accuracy is high); Generate letters for all patients on list (with clinic logo); Order fecal tests for all patients on list (bulk ordering) Interactive; real- time updates for stepped programs Non-interactive; one-time data pulls Registry Function

ExclusionWhere in chartDuration Diagnosis of Colon Cancer or colectomy Problem list, medical history, or any encounter Permanent Patient deceasedPatient status itemPermanent Returned mail/bad address Patient message #1581: Verify Patient Address Until message is marked as expired ColonoscopyReferral or order12 months ColonoscopyResult108 months FIT/FOBTOrder6 months FIT/FOBTResult12 months SigmoidoscopyReferral or order12 months SigmoidoscopyResult48 months Dialysis or palliative careReferralPermanent Sample exclusions

Plan-Do-Study-Act approach Implement change Assess findings Develop question Implement improveme nts ActPlan DoStudy

Selected PDSAs

EMR Work session process Empathy Mapping Divergent Thinking Affinity Mapping Convergent thinking What are concerns of typical consumer of the program? Ideas are grouped by topic, then prioritized. Describe the typical consumer of the program. Develop persona Possible solutions were identified for top priority. “Eliminate errors in ‘Z’ process” Individual ideas were written on post-its

Vote on the Most Important  Eliminate manual scrubbing and improve info at a glance  Decrease time to mail kit  Increase match between communication methods and patient preference  Decrease number of reports  Increase provider buy-in on FIT Kits  Increase interoperability between modules (PL, Surg hx, HMA)  Reduce time in searching for previous colonoscopy  Improve process by eliminating printing delay  Reduce time spent creating orders  Reduce time and materials by increasing patient portal use.  Reduce staff time by understanding individual status with a patient report

Conclusion  Multiple, iterative steps in designing and refining EMR tools for long-term use:  Assemble team  Select specifications  Develop and refine tools  Train staff  Repeat  Understanding clinic workflow and where data are stored in the EMR is important;  Start small, consider unintended consequences, and prepare for iterative process.

Acknowledgments Funding source: NIH Common Fund [UH2AT and 4UH3CA ] and Kaiser Permanente Community Benefit  STOP CRC Research Team;  OCHIN;  Participating Clinics  STOP CRC Advisory Board