Table 4 Lessons learned: implementation challenges (n = 55)
Summary of themes | PCP (n = 20) | Specialist (n = 23) | Leader (n = 12) | Sample of illustrative quotes (stakeholder group identified) |
|---|---|---|---|---|
Use of automated telephone outreach | ||||
Inadequate consideration of how the reminder program would interface with Medicare and Medicaid reimbursement regulations | ✓ | “I can’t overstate the importance of communication with External Affairs… in particular regarding Medicare guidelines about who is eligible for screening, and how reimbursement happened. So that was yet another whole layer of, okay, how do you [deal with] this so that the organization is in compliance with the federal regulation but isn’t burdening, you know, a thousand primary care clinicians. It… took a lot of work to get through that issue”. —HP manager | ||
IT department not involved early enough in program development to determine how automatic calling system would interface with EMR | ✓ | “You need an analyst who can not just supply the data you ask for, but make sure that you’re asking for the right data, and [that the data] are really going to meet your needs… I think they need to be integrally involved in the planning process. As well, you need an implementation person… [who] can maintain a picture of what’s going on… because you don’t want the project to become siloized, with everybody just working independently”. —HP manager | ||
Organization not prepared or staffed to meet the need for entering orders for patients who got fecal tests mailed after the reminder call | ✓ | “The analyst would put it into an Excel spreadsheet and then send a packet to our medical assistant, who would put in all those orders. Which could be, you know, eight hundred, twelve hundred orders. It’s a lot of ordering. However, recently, we have gotten a system in place that allows for batch ordering”. —HP manager | ||
Slow response in mailing out fecal test to those patients saying “yes” during the call negatively affected patient compliance and interest once kits arrived at patient’s home | ✓ | “It would take sometimes up to six weeks to get these mailed out, because we couldn’t mail them out without an order, because the lab can’t do anything with a kit that comes back that doesn’t have an order”. —HP leader | ||
Lack of integration or documentation of reminder calls in the EMR increased providers’ chance of not knowing a patient had been called | ✓ | ✓ | ✓ | The big deal [was] the complaints about not knowing which patients were called. And that’s just something that we can’t give them. But I think that that’s what leadership hears the most of”. —HP leader |
Use of fecal immunochemical tests | ||||
Need to improve clarity of instructions for fecal tests | ✓ | “I’ve had a number of patients tell me that the lab has said, don’t mail it back [fecal test]. You need to drop it back in. So I’m not sure if that’s an area that the organization has looked at… I’m not sure if our mailing package might need to change, or our instructions with the kit… But that would be one barrier to maybe getting it back if people have been told, either correctly or incorrectly, that they have to drop it off in person”. —PCP | ||
No clear process for labeling kits, both when distributed centrally or when distributed from the point of care | ✓ | “We had some problems with FIT tests coming back unlabeled. I don’t think it was a lot, but it was enough”. —HP manager | ||
System does not involve automatically sending fecal test kits in the mail to every person who is due following receipt of the automated reminder call | ✓ | “There are ways we can improve. I mean, we’re constantly kind of assessing… Southern Cal [Kaiser]… automatically sends the kit in the mail to every single person that’s due”. —HP manager | ||
Communication about organizational screening approach | ||||
Lack of effective and efficient ways to clearly communicate the organization’s CRC screening approach preferences to providers (PCPs/health teams/specialists) | ✓ | ✓ | “The challenge is always going to be making sure your physicians are excited about these kinds of screenings; not just for cancer, but for a variety of different things, and that they’re your best advocates… We need more of a unified voice behind our preferred screening modality”. —HP leader | |
Need for ways to effectively communicate and educate resource stewardship and evidence based outcomes to providers as they pertain to CRC screening | ✓ | ✓ | “If the patient wants a colonoscopy, that’s a very difficult discussion… because, if we’re still in the mode where we do what the patient wants, then we’re going to try to do [it] within a reasonable guideline. I don’t know how you remedy those two issues”. —GI specialist | |
Ongoing challenge of shifting the beliefs/habits of some providers (PCP and specialists) away from colonoscopy as the only appropriate screening choice for average-risk patients | ✓ | ✓ | ✓ | “I think it’s kind of a dilemma… If a friend of mine walks up and says, what test do you recommend to me? I would tell them colonoscopy… I think the colonoscopy is the best test”. —General surgeon |
Need to clarify roles, processes, and expectations between PCP and specialist regarding CRC screening follow-up issues | ✓ | “One challenge that is sometimes unclear is who’s going to follow the referral [surveillance colonoscopy after a positive initial screening colonoscopy]. Do specialists automatically send follow-up to the patient that you need another one because this is positive [showed polyps], or are they expecting us [the PCP] to automatically re-refer them?” —PCP | ||
Need for improvement in creating a service that integrates all components of the program, involving input and efforts of GI, surgery, oncology, and primary care | ✓ | “It’s an upgraded service program in the sense that you can’t do this without having oncology, surgery, GI and primary care [work] as an integrated team. I mean, the patient flow issue is related to both the screening program and the subsequent care. It’s not just one little cross sectional piece of care. It’s one piece of the integrated process”. —GI specialist | ||
Concerns about screening duplication | ||||
Patients new to the organization and with a recent negative colonoscopy being inappropriately given FIT kit | ✓ | ✓ | “We’ve seen any number of patients that come through with a positive FIT test who have actually had a negative colonoscopy within ten years. In my view… no one should be allowed to order another screening test [for them]”. —GI specialist | |
Lack of clarity on protocols and communication strategies by PCPs for patients with a negative FIT who also requested a screening colonoscopy | ✓ | ✓ | “A lot of people have been told by their primary care that if their FIT was negative they can’t get a colonoscopy. …They can. You just have to have it referred. There’s a several month waiting period. There are lots of messages sent to primary care about this”. —General surgeon | |
Approach of offering multiple screening methods and utilizing multiple outreach strategies of reminder calls and in-clinic prompting may be creating some screening duplication | ✓ | ✓ | ✓ | “Sometimes people get these stool cards at the Flu Clinic or by mail when they’ve already had a colonoscopy, or some other way they really shouldn’t have gotten one. And then they’ll bring them back and it’s positive”. —PCP |
Need to standardize documentation in EMR of patients’ prior CRC screening and related result so there is clear and easy access to information for all providers | ✓ | ✓ | “Sometimes it’s difficult using [EMR] what type of screening has previously been done. I’ve had referrals sent to me where someone gets referred for a colonoscopy and they had one three years ago… So far we don’t have a system-wide way to write it in the problem list. We’re trying to standardize that. And finding the notes when you’re just scanning the charts is very, very difficult… even if a physician is trying to really find that, it’s hard”. —GI specialist | |
Ongoing need for education | ||||
More patient education about CRC screening that can be delivered by support staff (MAs and RNs) | ✓ | ✓ | “Some patient education materials would be nice… anything that would summarize the pros and the cons of the different types of screening. And it wouldn’t be a bad idea for some of that material to be handed to the patients by support staff, so that while they’re waiting in the room they could look it over and then maybe be a little bit informed before the office visit”. —PCP | |
Create more consistent, uniform, centralized messages utilizing a variety of methods (e.g., visual aids for patient navigation, provider decision-trees, etc.) | ✓ | ✓ | “What might be helpful is if I had a FAQ sheet [for PCP] like what is the incidence of colon cancer for average risk patients, fifty to sixty, sixty to seventy, etc. What is the risk if there is a family history? And possibly a fact sheet for patients too, because it is definitely the patients who leave here who are undecided and they struggle or they have questions”. —PCP | |
Direct patients with a recent normal colonoscopy not to get a fecal test (FIT) | ✓ | “There [needs] to be a big bullet on the FIT test that says, if you had a normal colonoscopy within the last five years, throw this away immediately. These are automatically mailed out to patients who the year previously had a normal colonoscopy. Five to eight percent are positive, then they’re wanting another colonoscopy”. —General surgeon | ||
Proactively educate patients about choices and controversies related to screening | ✓ | “Anything that can be done to provide the patient with information about the controversy or choices, or how to pick up or get a test done… You take your FIT test and it is positive, this is what will subsequently [occur] in your care. So the patients sort of know where they’re going to go with this, what the expectations are, and what Kaiser will provide to them”. —General surgeon | ||
Increase staff and colonoscopy resources/access | ||||
Increased sensitivity and compliance of FIT. unintentionally created resource and access issues again with colonoscopy | ✓ | ✓ | “Because we’re screening more people, we’re finding more positive FITs and it’s driving our colonoscopy rates up. But they’re driven up appropriately… but this will require us to, again, strategize about what we’re going to do as an organization”. —HP leader | |
Continuing need for additional highly trained staff (including mid-level providers) to do screening colonoscopies, helping to improve wait-times and access | ✓ | ✓ | “We’re going to need more people capable of doing a good colonoscopy. We’ve been at the forefront in the past of hiring PAs and training them to do that. And right now there some considerations to do it, but that’s a big political thing”. —HP leader | |
Need to make CRC screening a self-referral program, similar to other screening programs (e.g., breast cancer screening) | ✓ | “Make it self-referral”. —General surgeon | ||