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Using EHRs For Quality Improvement:  Breast Cancer Screening

Dr. McGrath has attested to Meaningful Use and his first incentive check is in the mail. He has harmonized his elective quality measures around cancer screenings because his EHR product is certified for screening measures, and he consistently gets the same denominator with accurate reports. Dr. McGrath discovers the rate of breast cancer screening among his eligible patients is much lower than he'd like. An REC representative works with the practice's staff and their EHR vendor to review the system's functionality, run reports, and confirm accuracy. As a strong advocate of providing preventive care, particularly prevention of cancer deaths, Dr. McGrath wants to learn about systematic ways to improve. First, the REC representative advises Dr. McGrath to generate a patient list that identifies the names, addresses, and phone numbers of all appropriate patients in his practice who have not been screened. The REC representative then presents Dr. McGrath with these potential options:

Engage at Risk Patients

  • Identify the patient's preferred method of receiving reminders and utilize that method to remind her to come into the office.
  • If the patient does not respond to electronic or mail reminders, schedule an office visit.
  • Discuss any barriers to receiving a mammogram ‐ e.g. fear of the procedure, cost issues, or side effects.

Use EHRs to Engage Patients

  • Activate clinical decision support (CDS) rules:
    • Use patient birthdates and gender to create breast cancer screening CDS rules
    • Use these rules to generate postcards or secure e-messages reminders; Conduct pre-visit planning to identify due and overdue mammogram services and discuss during the patient's visit.
    • Review problem lists for exclusions (e.g. patients who have had a mastectomy).
    • Engage women aged 40 to 49 in a discussion about the need for a mammography, as recommendations for this age group are mixed1.
  • Provide patient educational materials
    • Use print-outs, websites, and/or kiosks specified for a low-health literacy audience.
    • Identify specific materials to address screenings for women between the ages of 40 and 49.
    • Practice staff should utilize material to educate patients and should use teach back to assess patient knowledge during subsequent visits.

Implement a Workflow that Supports Quality Improvement

  • Initiate workflow changes with one provider:
    • Identify staff member roles and appropriate place for documentation with the EHR system.
    • Run process measures to see if process is consistent
    • Repeat measurement and assess if improvement has occurred
    • Employ a team huddle before each of these clinic sessions
      • Review the patients who have had difficulty with adherence from the entire staff’s perspective
      • Use hypothetical cases to ensure that the team understands the protocols well
      • Ensure that patient information is gathered and / or obtained as appropriate
      • Divide important educational tasks; shared decision-making with women aged 40-49 will be particularly important.
    • Continue the process with additional providers and establish staff meetings to give provider-specific feedback
      • Provide feedback during team meetings, as the incentive to adhere to workflow changes and achieve improvement is intensified if providers are compared to their peers.

1 ACS and USPTF have opposing recommendations on the initial age for mammography. Each practice should have a clear policy on mammogram recommendations for this age group and have it incorporated into practice workflow. Current consensus suggests a shared decision-making approach that incorporates individual breast cancer risk and patient's values, e.g. concern for false positive results and related procedures vs. fear of cancer.

Produced by Meaningful Use Quality Workgroup - August 29, 2012

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