Donald E. Nease, Jr., MD, and others from the department of family medicine at the University of Michigan Medical Center in Ann Arbor wanted to find out whether primary care practices (PCPs) could use computers to increase the rate of colorectal cancer screening.
Donald E. Nease, Jr., MD, and others from the department of family medicine at the University of Michigan Medical Center in Ann Arbor wanted to find out whether primary care practices (PCPs) could use computers to increase the rate of colorectal cancer screening. They installed ClinfoTracker software (sold today as Cielo Clinic) as part of the Prompting and Reminding at Encounters for Prevention (PREP) program, a project funded by the National Cancer Institute.
Researchers conducted PREP from 2003-2005 in 12 community practices that are part of the Great Lakes Research into Practice Network (GRIN). Participating practices implemented the ClinfoTracker system, which applies the US Preventive Services Task Force guidelines to prompt physicians and patients when a patient should undergo screening. This study used only the colorectal cancer screening reminders.
In 8 of the 12 practices, physicians received printed reminders for patients who met the general guidelines for colorectal screening based on their age and history of prior screening; in the remaining 4 practices, both physicians and patients received the reminders.
After 9 months, Dr. Nease and colleagues found that 11 practices increased colorectal cancer screening rates by 3.3% to 16.8% (average 9%). As expected, researchers observed the greatest improvement in practices that used higher levels of technology prior to the start of the study. “Our philosophy is that quality improvement should be a team sport that all parts of a practice play in and benefit from,” says Dr. Nease. “For example tracking patients’ screening status benefits the doctors when they are seeing patients as they have information where they need it, when they need it. The office staff also benefits from being able to generate reminder letters to patients when needed.”
Dr. Nease explained adds, “Traditionally, doctors have used paper flow sheets to track problems, screening suggestions, and testing needs. That works at the individual patient level, but you really don’t have the ability to take it any further. A computerized system allows doctors to record whether a test was ordered, completed, discussed with the patient, or refused. Those ordered but not completed are flagged by the computer for follow-up.”
In an effort to make this system more widely available, Dr. Nease and colleagues worked with the University of Michigan’s Office of Technology Transfer to license the software to Cielo MedSolutions, LLC. Cielo added a feature for managing patients with other chronic diseases, renamed the program Cielo Clinic, and now offers it for commercial sale to medical practices nationwide.
A program like Cielo Clinic is known as a decision-support system (DSS). One of the primary functions of this type of program is to provide preventive care reminders. That is only scratching the surface of possible uses for a DSS, however, especially in practices that use electronic medical records (EMR) and computerized order entry.
“When integrated with physician computerized order entry, [using a] DSS for medications can dramatically benefit oncologists and their patients," says Paul Dexter, MD, chief medical information officer for Wishard Health Services and an investigator for Regenstrief Institute in Indianapolis, Indiana. “Chemotherapy regimens are often very complex. DSS can alert the physician to possible drug interactions or changes in dosage required because the patient has kidney problems [for example].”
In addition to issuing screening and medication reminders, these programs can alert members of the treatment team to required follow-up measures. For instance, if a patients is taking medication that requires blood value tracking (such as patients with chronic myeloid leukemia who take imatinib mesylate), DSS tells the physician that a draw is needed at the next visit and keeps the reminder in front of the physician until he or she indicates that the test was completed.
If facilities in the same healthcare community agreed to use an integrated system, the DSS could then assist with continuity of care issues. This would foster many opportunities to improve patient care, particularly for patients with cancer. “Oncology patients are often simultaneously followed by oncologists, primary care physicians, and other specialists,” explains Dr. Dexter. “The ability to share information [among these groups] in something approaching real time can be useful and, in some cases, lifesaving.”
Similarly, a DSS can help keep abreast of patients on research protocols. “Oncology is one of the most developed specialties as far as research in community settings,” says Dr. Dexter. He notes that computers could help oncologists quickly identify chemotherapy regimens “on the leading edge” of knowledge.
Another area of oncology where computers have shown promise is in diagnostics. Studies have shown that two people (double reading) reviewing mammography films improved cancer detection rates by 10% compared with single reading. A recent trial from Europe compared double reading to single reading accompanied by computer-aided diagnosis (CAD). They found no significant differences between double reading and single reading plus CAD in detection, sensitivity, specificity, and positive predictive value. The authors suggest that using CAD could decrease the burden on resources:
Double reading, which is recognized as the best method for thedetection of small invasive cancers, is often difficult toachieve in practice because of costs and the need for two readers. The results of this study are applicable to programs in whichdouble reading is standard practice. Where single reading isstandard practice, computer-aided detection has the potential to improve cancer-detection rates to the level achieved by doublereading.
Although studies on using CAD to detect polyps in the colon and nodules in lung cancer are still in early stages, results have been promising.
Researchers continue to examine ways in which medical practices can implement computerized systems to improve patient care. At a cost of up to $50,000 per physician, making the transition from old-fashioned ink-and-paper recordkeeping can be expensive, which is the main reason many clinical practices have yet to make the leap. There are also privacy and security concerns, with some reports of electronic medical records being breached by unscrupulous employees or hackers. Still, some experts believe moving to integrated computerized systems has the potential to save the nation billions in healthcare costs over time and substantially reduce medical errors.
FJ Gilbert, et al. Single reading with computer-aided detection for screening mammography. New Engl J Med. 2008;359(16):1675-1684.
Kurt Ullman is a freelance health and medical writer based out of Indianapolis.