SCREENING THE UNSCREENED

GETTING IT GETTINGit Right

How Can We Screen the Unscreened?

Karen E. Kim, MD, MS Professor of Medicine University of Chicago

DESPITE ADVANCES IN COLORECTAL CANCER (CRC) SCREENING, FAR TOO MANY INDIVIDUALS ARE

NOT BEING SCREENED. The problem is particularly acute at the 1,250 federally qualified health centers (FQHCs) with 8,000 service sites nationwide who provide the highest proportion of primary care to our nation’s most vulnerable and underserved populations. In 2016, FQHCs provided primary care services to more than 25 million patients, 65% being racial/ethnic minority populations and 23% uninsured. Unfortunately, among these vulnerable populations, CRC screening rates at FQHCs are significantly lower at 35% compared with the national average of 62%. There are numerous system- and providerlevel barriers which contribute to these low screening rates including cost, access and poor communication. Many FQHC providers use FOBT/FIT as the initial screening option, but follow-up for those found to have a positive test is often delayed or never results in a completed diagnostic exam. The lack of specialty access for colonoscopy services within our nation’s safety net systems is a significant problem, with the average wait of 18 months to complete a diagnostic colonoscopy. This alone can significantly contribute to disparities in CRC mortality, with studies showing that a one-year delay in follow-up for a positive FIT can lead to a two-fold increase in CRC risk. How can we close this gap to reduce the unnecessary burden of disease? 

ILColonCARES.org ILColonCARES.org ILColonCARES.org solves the problem of system fragmentation. solves the problem of system fragmentation. solves the problem of system fragmentation.

Clinic Clinic

Clinic schedules schedules appointments at Point of Service appointments at Point of Service schedules appointments at Point of Service

Hospital Hospital Hospital

fills fills colonoscopy slots colonoscopy slots fills colonoscopy slots

Patient

Patient

Patient

gets gets screened screenedgets screened

Completion of colonoscopy and REDUCE Colorectal Cancer Burden Completion of colonoscopy and REDUCE Colorectal Cancer Burden Completion of colonoscopy and REDUCE Colorectal Cancer Burden

Our fragmented health care system their doctor’s office, more than 50% two very different user bases: (1) FQHC plays an important role in impeding will not complete their exam. This has providers in need of colonoscopy slots 5 access to colonoscopy services. A recent report showed that 80% of serious a significant downstream effect, with between 14-24% of all colonoscopy slots for their FOBT/FIT-positive patients, to make appointments for their patients and medical errors could be attributed to being unfilled. The end result is patients send clinic notes; and (2) hospital partners miscommunication among medical who remain unscreened and hospitals who post their open slots, accept referrals staff, with more than 50% due to poor who are wasting resources. and appointments, capture notes from the provider-to-provider communication. To address these barriers, me and my providers, and communicate findings. A key In fact, more than 50% of referring team received funds from the Centers innovation of this portal is the ability for providers have no communication with for Disease Control and Prevention point-of-service scheduling. Point-of-service the specialist, while 50% of specialists to develop an innovative web-based scheduling has been shown to significantly do not send information back to their platform—ILColonCARES.org—to increase receipt of services. Partner hospitals referring providers. The challenges of connect FIT-positive patients from upload their available colonoscopy slots to failed communication can be attributed FQHCs with colonoscopy slots at local the website, including the date and time, two to multiple causes, the most important hospitals. ILColonCARES.org is HIPAA weeks in advance. Clinics can see the open being unintegrated health care systems. compliant and was designed to link colonoscopy slots, schedule their patients, The most significant outcome from non-networked health care systems to provide bowel prep instructions, and upload this poor communication falls on the specialty services. This portal overcomes any medical information into the portal shoulder of our patients. Studies show system fragmentation to successfully before their patients leave their clinic visit. that only one out of every two referrals complete colonoscopy services across Once the patient completes their procedure, results in an actual appointment, and systems by: (1) providing access to care hospitals upload the colonoscopy report, 40% of these cases are failed scheduling. for patients; (2) establishing point-of- any pertinent findings, quality metrics (e.g. In fact, we know that when patients in care scheduling; and (3) facilitating bowel preparation, number of polyps found, need of colonoscopy services are not bidirectional communication. The withdrawal time) and interval follow-up given an appointment before they leave IL Colon CARES program handles into the portal to close the communication loop. ILColonCARES.org is an innovative platform which has broad application for

ILColonCARES.org is an end-to-end solution for linkage to increasing endoscopy capacity, reducing specialty care services. unfilled slots, and ensuring everyone receives high-quality, timely CRC screening Innovative web-based HIPAA-compliant and follow-up care. software:

• Connects out-of-network (decentralized) healthcare systems • Provides physician-to-physician communication

• Linkage to specialty care services with followup reporting

References

Miglioretti DL, Rutter CM, Bradford SC, Zauber AG, Kessler LG, Feuer EJ, Grossman DC. Improvement in the diagnostic evaluation of a positive fecal occult blood test in an integrated health care organization. Med Care. 2008; 46(9 Suppl 1):S91-96.

Forrest CB, Nutting P, Werner JJ, Starfield B, von Schrader S, Rohde C. Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study. Med Care 2003; 41(2):242-53.