Mapping Colorectal Cancer Screening Workflows in Primary Care Practices

Context: Primary care physicians and practice teams face well-documented challenges increasing colorectal cancer (CRC) screening rates among their patients. These include competing demands, complex and changing guidelines, and inadequate tracking systems. Multi-level interventions that address patients, clinicians, clinical care environments and larger systems (hospitals, networks, etc.) are needed to reach US CRC screening goals. Understanding how CRC screening happens (or does not) in this dynamic environment is an important prerequisite to intervention to improve screening rates.

Objective: Examine CRC workflows in a variety of primary care contexts to examine similarities and differences across sites.

Study Design and Analysis: Prospective mixed-methods study investigating CRC screening workflows for different screening modalities and describing implementation of those workflows from clinical staff perspectives.

Setting or Dataset: Eight US primary care practices.

Population Studied: Twenty-seven staff, including physicians, nurses, office managers, medical assistants, receptionists, and others.

Intervention/Instrument: Individual semi-structured interviews of all practice staff exploring domains of CRC screening: identification of eligible patients, screening recommendation messaging, clinical conversation, test ordering, and test results follow-up.

Outcome Measures: Process map that illuminates workflow of CRC screening in participating clinics.

Results: Various practice staff report playing roles in each of the domains examined here. Office and non-physician staff identify eligible patients, provide screening education, process test orders, and ensure follow up on test results. Physicians and advance practice clinicians (APCs) engage in clinical conversations by describing test procedures and recommending screening methods. Physicians/APCs primarily communicate positive results to patients, while other practice staff notify patients of negative results. Eligible patients are identified through EMR screening tools, insurance databases, and manual chart reviews. Practices most often offer patients Cologuard® or Colonoscopy depending on patient risk, familial history, or past screening results. Test ordering and results reporting are based on test selected and local accessibility of services.

Conclusions: Understanding specific steps and clinical staff roles in CRC screening will support design of interventions aimed at improving screening rates.