Designing Colorectal Cancer Screening Decision Support

Abstract

Adoption of clinical decision support has been limited. Important barriers include an emphasis on algorithmic approaches to decision support that do not align well with clinical work flow and human decision strategies, and the expense and challenge of developing, implementing, and refining decision support features in existing electronic health records (EHRs). We applied decision-centered design to create a modular software application to support physicians in managing and tracking colorectal cancer screening. Using decision-centered design facilitates a thorough understanding of cognitive support requirements from an end user perspective as a foundation for design. In this project, we used an iterative design process, including ethnographic observation and cognitive task analysis, to move from an initial design concept to a working modular software application called the Screening & Surveillance App. The beta version is tailored to work with the Veterans Health Administration’s EHR Computerized Patient Record System (CPRS). Primary care providers using the beta version Screening & Surveillance App more accurately answered questions about patients and found relevant information more quickly compared to those using CPRS alone. Primary care providers also reported reduced mental effort and rated the Screening & Surveillance App positively for usability.

Healthcare information systems: the cognitive challenge

“…Although managing and tracking colorectal cancer screening appears to be a simple problem readily resolved with rule-based reminders, screening rates remain well short of the 80% target established by The National Colorectal Cancer Roundtable [ 44 ]. Militello, et al [ 45 ] developed a colorectal Screening and Surveillance App that was designed to work with the US Veterans Health Administration’s Computerized Patient Record System. For their development, they used Decision-Centered Design to identify the challenging decisions faced by clinicians in managing and tracking colorectal cancer screening and then design a cognitive support system for that work.…”

“…Militello, et al [ 45 ] configured their colorectal Screening and Surveillance App to support these three macro-cognitive processes. The App encouraged a mix of skill-, rule-, and knowledge-based processing by use of an information representation that helped the primary-care provider navigate skillfully to key information that would support knowledge-based processing in service of complex macro-cognitive processes such as sensemaking, problem detection, and collaborative decision making.…”

“…Militello, et al [ 45 ] also developed a one-page educational brochure designed to help a primary-care provider discuss screening options for, and common misconceptions about colorectal cancer with their patients. Although the Center for Disease Control already had a two-page brochure on this topic, this new one-page brochure was designed to be easier to view on a screen, easier to print, and less daunting to read [ 46 ].…”

Evaluating a Modular Decision Support Application For Colorectal Cancer Screening

“…One strategy for increasing screening rates among patients is to improve the accessibility of CRC related information for their PCCs. We designed and developed a modular decision support application, the Screening and Surveillance App [19], to help PCCs track and manage their patients' CRC screening regardless of whether the patient is in routine screening mode, or in surveillance mode based on prior findings.…”

“…The need for a conversation between patient and clinician about CRC screening is often triggered by a clinical reminder or alert in the EHR; however, it is often difficult to find the data needed to make a patient-centered CRC testing recommendation and have a meaningful conversation with the patient [19]. The Screening and Surveillance App is designed to ensure that the primary care clinician has key information at-a-glance when it is most needed.…”