Provider Reminder Planning Guide

Introduction

The four Evidence-Based Intervention Planning Guides provide tips to help clinic staff, and those who provide technical assistance to them, implement evidence-based interventions to increase screening for breast, cervical, and colorectal cancer.

Provider reminders help ensure that patients due for cancer screening receive a screening referral or recommendation. See the Community Guide recommendation.

Process flow

Implement and integrate a provider reminder system into the clinic workflow

When a reminder is sent and received, the provider is prompted to action.

Output: Increased prompts to providers

Measure: Provider prompts.

Example: Number of charts with prompts placed divided by the number of patients due for screening with appointments.

Provider recommends cancer screening consistent with screening guidelines and recommendations

Potential challenges include a limited electronic health record (EHR) system, the list of patients due for screening is not generated automatically, and lack of staff time to flag charts.

Output: Increased screening recommendations made by providers

Measure: Screening recommendations, referrals, or orders.

Example: Number of patients given a recommendation by a provider divided by the number of patients due for screening with appointments.

Example: Number of patients with a screening test ordered divided by the number of patients due for screening with appointments.

Patient completes cancer screening

Potential challenges include inconvenient clinic hours, limited capacity or resources to follow up on abnormal screening results, patient fear, cost, and lack of transportation.

Outcome: Increased screening and diagnostic tests completed by patients

Measure: Screening completion.

Example: Number of patients completing screening divided by the number of patients referred for screening.

Example: Number of patients completing diagnostic follow-up divided by the number of patients with positive screening tests.

Increased cancer screening

Outcome: Increased clinic-level rates of cancer screening

Measure: Age-eligible clinic population up-to-date with recommended cancer screening.

Example: Uniform Data System (UDS), Healthcare Effectiveness Data and Information Set (HEDIS), National Quality Forum (NQF) 12-month measure used to calculate screening rate.

Components of the intervention

Identify patients due for screening tests

• Has a priority population been identified?
• Can patients who are due for screening or rescreening using the EHR or other patient record system be identified?

Create a reminder system

• How will the reminder be delivered to the provider?
• Can the reminder be created within the EHR system?
• Has a person been assigned to place flags in paper charts if necessary? Is the task part of the clinic workflow process?
• Is the meaning of the reminder or flag clear? Does the reminder explicitly state that the patient is due for cancer screening? If not, has the meaning been agreed upon previously and understood by all clinic staff?
• Have staff been trained on the system? Note whether providers can turn off notifications within the EHR and consider how to handle.

Track outcomes

• Is there a way to track whether the provider recommended or ordered a screening test?
• Is there a way to track patients through screening and diagnostic test completion?
• Has a method and tools for tracking been identified or created?
• Have appropriate and feasible performance measures been selected for process and outcome evaluation?

Resources to support implementation

Partnerships

• Internal: Across and within clinics, with departments such as billing, claims, laboratories, radiology, and information technology (IT).
• External: Patient registries, laboratories, Primary Care Association, external health IT consultants.

Staff

• Providers who recommend or administer tests to patients.
• Administrative support to identify patients due for screening, develop the reminder system, place reminders (stickers, flags, checklists, papers, electronic flags), update charts, and follow up with patients who do not make appointments.

Training

Train all staff members involved in the provider reminders process on the delivery steps, screening guidelines and recommendations, system monitoring, and evaluation.

Technical assistance

• Designate a point of contact to provide ongoing assistance for the reminder system.
• Share information about cancer-related resources and services.

Tools

Computerized patient registry or electronic health records if the practice has a system that can be used for reminders.

Lessons learned from the literature¹

• Provider reminders worked for patients who had never or seldom been screened as well as for those who have been screened.
• Outcomes were similar for provider reminders that were electronic or manual, tailored or generic, and regardless of the provider's training status (intern, fellow, resident, attending).
• Provider reminder interventions that impose less change to existing systems or processes were adopted more easily and worked as well as complex systems. Simple reminder systems were also easier to sustain.
• Consider pilot testing the reminder system before scaling up.
• Provider reminders do not reach individuals who are not connected to a health care system.
• For all screening modalities, the effect of provider reminders appeared to diminish over time.
• Provider reminders may be used to increase multiple preventive services linked to the system.

Ways to strengthen performance or sustainability

• Periodically adjust or enhance the reminder system to maintain effect; for example, disable providers' ability to turn off reminders and add training refreshers for clinic staff.
• If possible, program the EHR system to flag patients due for screening automatically as consistent with screening guidelines or recommendations. Some EHR systems may require an action by the provider that can serve as a record that the prompt was received.
• Adding color-coded stickers or cards in the patient's physical chart can prompt follow-up to ensure that a recommended screening has been completed.
• Incentivize appropriate recommendation practices by inspiring competition among clinics or providers using performance monitoring metrics.
• Couple provider reminders with other evidence-based approaches as a multi-component strategy to follow up with patients who do not complete recommended screening.
• Educate or remind physicians that a provider's recommendation is a top reason why patients get screened.^{2 3}

Community Guide recommendation

The Community Preventive Services Task Force recommends the use of provider reminder systems to increase screening for breast, cervical, and colorectal cancer.⁴

Settings where the intervention was studied¹

• Rural, urban, and metro areas in the United States, United Kingdom, Italy, Australia, Israel, and Canada.
• Hospitals, individual and group primary care practices, federally qualified health centers, and other community health centers.

Outcomes from the systematic review of effectiveness¹

• Completed breast, cervical, and colorectal cancer screenings increased by a median of 7.2 percentage points for all tests.
• Cost of the intervention (per additional screening test completed):
  • Mammography: After one reminder, $75; if additional reminders were required, $118.
  • Pap test: Less than $20 for a computer-printed message, tagged group files, or notation in the medical chart. A list of patients due for screening sent to the provider by memorandum cost more than $60 (more than 3 times as much).
  • Consider that successful implementation of the intervention may result in increased costs such as management for increased clinic attendance and consultation costs associated with flag use.

References

¹Baron RC, Melillo S, Rimer BK, et. al. Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: a systematic review of provider reminders. Am J Prev Med. 2010;38(1):110–117.

²Peterson EB, Ostroff JS, DuHamel KN, et. al. Impact of provider-patient communication on cancer screening adherence: A systematic review. Prev Med. 2016; 93:96–105.

³Steinwachs D, Allen JD, Barlow WE, et. al. National Institutes of Health state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening. Ann Intern Med. 2010;152(10):663–667.

⁴Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2012;43(1):92–96.