STAGE 7 SPOTLIGHT Legacy Health: Increasing Cancer Screening Rates
The Electronic Medical Records Adoption Model (EMRAM) is a globally recognized framework for the implementation and effective use of health information technology within healthcare organizations. Healthcare organizations all over the world have used the EMRAM to improve all aspects of patient care- from reducing emergency department overflow and preventing unnecessary orders of blood transfusions, to treating clinical depression; all while saving lives.
EMRAM Stage 7 achievement is the recognition of a healthcare organization's commitment to improving the quality, delivery and cost of healthcare through the use of health IT. Let's dive into the implementation process of one such organization, Legacy Health.
Located in the Portland Metropolitan Area and Southwest Washington, Legacy Health is staffed by more than 13,000 employees and comprised of six hospitals, 80 primary care and specialty clinics and has 1,641 licensed beds. Throughout this vast healthcare system there was a challenge: accurate data collection and analysis of colon cancer screening rates.
Although incident rates have been declining annually due to an increase in screening, colorectal cancer remains the third leading cause of cancer deaths in the United States; in 2018, colorectal cancer will cause an estimated 50,630 deaths. With early screening and detection by any recommended method (colonoscopy, FIT, sigmoidoscopy), pre-cancerous polyps can be eradicated; early-stage cancer requires less extensive treatment to achieve remission.
Legacy Health was struggling to accurately collect all of the data they were receiving; the organization supported multiple Electronic Medical Record (EMR) systems concurrently, making accurate data collection and analysis of cancer screening rates nearly impossible. After implementing an enterprise-wide EMR, Legacy Health compared baseline colon cancer screening rates among the primary care population to other similar health systems in their community, and found that their screening rates were significantly lower.
In the beginning of their journey toward Stage 7 validation, they hoped to identify the root cause for these low screening rates, develop a plan for improving them and, ultimately, exceed the community standard.
The EMRAM Implementation
Legacy Health implemented a multi-phased, cross-departmental plan to improve screening rates. First, they implemented clinical decision support (CDS) reminders, designed to aid primary care providers in making informed decisions about a patient's care. These reminders would alert the provider in the EMR system if the patient met the criteria for screening but had no screening tests on record.
After implementing these reminders, the team at Legacy Health discovered that many of the screening tests were not documented in their EMR, because they had been completed at a different location, sometimes up to 10 years previously. To prevent this gap in data, they developed a standard workflow for identifying, obtaining and documenting the screening tests. They also included a link within the EMR for the provider to quickly order the appropriate tests when necessary. These measures alone lead to a 3 percent increase in screening rates.
As the EMR technology evolved, so did the workflows around preventative screening. Legacy Health was able to improve screening rates an additional 6 percent by implementing wellness registries, standardized reporting, patient level outreach tracking methods and standardized tools for bulk communications to patients. Screening rates improved by another 2 percent when Legacy Health added patient-facing reminders within the patient's personal health record (PHR), as well as automated email notifications sent from the EMR.
Over a three-year period, the total increase in screening rates for colorectal cancer was 11 percent. This increase led to early detection of colorectal cancers and improved mortality rates.
As historical screening tests were documented by clinical staff, duplicate and unnecessary testing was reduced, which also cut down on the amount of time providers wasted researching past records. Because the CDS alerts and order links appeared only when screening was due, the providers' cognitive workload was also reduced. Additionally, patients valued the automated reminders and used them to prompt further, more informed conversations with primary care providers.
With a multidisciplinary team, incremental change over the course of months, standardized methodologies and a centralized model of training for clinical staff, the team at Legacy Health was able to adopt the small changes one by one, leading to a large improvement over time.
“Utilizing the Epic tools and reminders in combination with enhanced reporting and giving the right people in the clinic the right information at the right time to intervene has made a positive impact both on patient care as well as provider well-being," said Melinda Muller, Clinical VP for Care Transformation. "The providers [are] doing more of the right care but with less work.”
Like the team at Legacy Health, other healthcare organizations can use the EMRAM as a roadmap for identifying challenges, understanding the underlying causes of those challenges, developing a standardized plan for addressing and implementing data-driven solutions. The path to EMRAM Stage 7 validation is a path to transforming the quality, delivery and outcomes of patient care.