Problem: The Florida Department of Health (FDOH) sought to increase utilization of electronic health record (EHR) systems for early detection and prevention of cancers through provider prompts/reminders in populations experiencing low socio-economic status and geographically disparities.
PSE Change Solution: Using a survey approach, FDOH Bureau of Tobacco Free Florida’s (BTFF) tobacco and cancer programs reached out to Federally Qualified Health Centers (FQHC), free and charitable clinics, and rural health network clinics to assess their readiness to implement systems change to increase tobacco cessation referral and cancer prevention and early detection. Responses were received from 13 clinics. Eight clinics expressed interest in receiving technical assistance to improve cancer screening workflow processes and tobacco cessation referrals. The BTFF tobacco and cancer programs worked with these clinics to implement systems change to increase tobacco cessation referral and cancer prevention and early detection.
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Electronic health record (EHR) systems can improve provision of preventive cancer care, health care quality, and patient outcomes (Atasoy et al., 2019; Green et al., 2013). Studies have shown that EHRs can specifically be used to improve tobacco cessation processes and measure effectiveness of interventions with smokers (Bernstein et al., 2019; Moody-Thomas et al., 2015). In addition, research has demonstrated that an EHR-linked reminder intervention can increase the number of patients who are current with their colorectal screening (Green et al., 2013). This systems change intervention, conducted by the Florida Department of Health (FDOH), aims to increase utilization of EHR systems for early detection and prevention of cancers through provider prompts/reminders in low socio-economic status (SES) and geographically disparate populations.
Provider prompts are an evidence-based tool for managing prevention procedures (Baron et al., 2010). EHRs can support cancer prevention and early detection by providing cues for physicians and their teams to take action. They capture the date a recommendation is given, the type of test recommended, and the patient’s test results. If additional follow-up is needed, EHRs track and record whether a referral was made and what follow-up tests were performed. Additionally, data reports monitor whether screening and all necessary follow-up tests are completed in a timely manner. Using a survey approach, FDOH Bureau of Tobacco Free Florida’s (BTFF) tobacco and cancer programs reached out to Federally Qualified Health Centers (FQHC), free and charitable clinics, and rural health network clinics to assess their readiness to implement systems change to increase tobacco cessation referral and cancer prevention and early detection. Populations served at these clinics are typically low SES and geographically disparate with reduced access to quality health care and limited insurance or funds to support their care needs.
Staff within the BTFF tobacco and cancer programs met to plan the project and draft a short survey to assess current clinic screening practices. The Florida Regional Cancer Control Collaboratives, American Cancer Society, and Florida Association of Community Health Centers partnered to review and refine the survey (Step 1: Engage). The Florida Association of Community Health Centers sent an email with a description and a survey link to its 42 FQHC medical directors statewide. Since response was low (6 out of 42), BTFF recruited the Florida Association of Free and Charitable Clinics to include a link in their newsletter that is sent to their 126 members. The Suwannee River Area Health Education Center, WellFlorida Council, Inc., and Health Council of East Central Florida, Inc., also reached out to their colleagues to encourage completion of the survey. Specifically, they sent the link through the Rural Health Network’s newsletter that reaches 157 rural clinics.
Responses were received from 13 clinics. Nine of the 13 respondents reported that their EHR systems included structured data fields to capture screening for tobacco use, human papillomavirus (HPV) vaccination, HPV testing, PAP testing, mammogram, colon cancer screening, and prostate-specific antigen (PSA) test. EHR systems at five clinics included clinical decision supports. Eight clinics expressed interest in receiving technical assistance to improve cancer screening workflow processes and tobacco cessation referrals. The BTFF tobacco and cancer programs will work with these eight clinics to implement systems change to increase tobacco cessation referral and cancer prevention and early detection.
Success Factors and Key Questions Addressed
What was the ultimate purpose of the PSE change effort? What was your “ask?”
Our goal is to identify opportunities for implementing systems change to increase tobacco cessation referral and cancer prevention and early detection in primary care clinics. To further that goal, health systems were asked to provide information about EHR capacity and provider prompts/reminders to improve workflows, processes, and patient outcomes. BTFF also wanted to approach technical assistance for all cancer prevention areas at the same time, instead of dealing with them one by one.
What level of PSE change was necessary (local, state, federal or institutional)?
The survey was administered statewide. Implementation will occur at a local level within each health system.
Who was already attempting PSE change efforts around the health issue?
The American Cancer Society (ACS) and the Florida Association of Community Health Centers (FACHC) were providing quality improvement and technical assistance to FQHCs. The FDOH Cancer Program partnered with ACS and FACHC to provide a Colorectal Cancer Screening Quality Improvement Bootcamp and Learning Collaborative to a cohort of 14 FQHCs. FQHCs implemented evidence-based strategic plans and further evaluated where gaps in screening could be bridged through data, decisive assessment, and impactful Quality Improvement Teams. The project concluded June 2020. FACHC and ACS continue to provide technical assistance to the cohort centers, as requested.
Was the environment conducive to the PSE change effort? What challenges did the scan reveal (economic, political, social, legal, etc.)?
The environment was conducive to the PSE change effort, because ACS had been working with FQHCs on health care quality improvement, setting the stage for the review of additional cancer screening practices and tobacco cessation. Challenges include the current focus of resources on COVID-19, which reduces the capacity of the clinics to expand quality improvement processes to additional health care areas. At the same time, dissemination of surveys has multiplied, given the reduction of face-to-face interactions, resulting in potential survey fatigue as a possible explanation for the low response rate.
What are the next steps of your PSE change initiative?
The immediate next step will be for BTFF to analyze and review survey data and discuss the results of the surveys with ACS and Area Health Education Centers that will also be involved with the projects. In the future, BTFF will select clinics to receive funding for EHR improvements and for technical assistance; determine funding amount(s); establish timeline of projects; and execute formal agreements.
Atasoy, H., Greenwood, B. N., & McCullough, J. S. (2019). The digitization of patient care: A review of the effects of electronic health records on health care quality and utilization. Annual Review of Public Health, 40, 487-500. https://doi.org/10.1146/annurev-publhealth-040218-044206
Baron, R. C., Melillo, S., Rimer, B. K., Coates, R. J., Kerner, J., Habarta, N., Chattopadhyay, S., Sabatino, S. A., Elder, R., Jackson Leeks, K., & Task Force on Community Preventive Services. Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by health providers: A systematic review of provider reminders. (2010). American Journal of Preventive Medicine 38(1), 110-117. https://doi.org/10.1016/j.amepre.2009.09.031
Bernstein, S. L., Weiss, J., DeWitt, M., Tetrault, J. M., Hsiao, A. L., Dziura, J., Sussman, S., Miller, T., Carpenter, K., O’Connor, P., & Toll, B. (2019). A randomized trial of decision support for tobacco dependence treatment in an inpatient electronic medical record: clinical results. Implementation Science, 14(8). https://doi.org/10.1186/s13012-019-0856-8
Green, B. B., Wang, C. Y., Anderson, M. L., Chubak, J., Meenan, R. T., Vernon, S. W., & Fuller, S. (2013). An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Annals of Internal Medicine, 158(5 Pt 1), 301-311. https://doi.org/10.7326/0003-4819-158-5-201303050-00002
Moody-Thomas, S., Nasuti, L., Yi, Y., Celestin, M. D., Jr, Horswell, R., & Land, T. G. (2015). Effect of systems change and use of electronic health records on quit rates among tobacco users in a public hospital system. American Journal of Public Health, 105(Suppl 2), e1–e7. https://doi.org/10.2105/AJPH.2014.302274
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