Opportunities and Challenges When Using the Electronic Health Record for Practice-Integrated Patient-Facing Interventions: The e-Assist Colon Health Randomized Trial

Abstract

Background Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening. Design Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention’s effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients. Results A total of 1825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material. Conclusions By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective. Implications Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population. Highlights Electronic health record tools can be used to facilitate practice-embedded pragmatic trial and patient-facing intervention processes, including patient identification, study arm allocation, and intervention delivery. The online portal-embedded intervention did not improve colorectal cancer (CRC) screening uptake following a physician recommendation, likely in part because portal users tend to be already highly engaged with healthcare. Relying on patient portals alone for CRC screening interventions may not alter screening use and could exacerbate well-known care disparities.

Colorectal Cancer Screening: We Still Have Work to Do

“…The findings in the Lafata et al (2022) study regarding Black adults are worrisome in that African Americans exhibit higher cancer death rates and lower survival rates compared with other racial or ethnic groups (DeSantis, Miller, Goding Sauer, Jemal, & Siegel, 2019). Roy et al (2021) found that strategies to increase stool blood testing in African Americans include standard mailed blood stool tests augmented by patient navigation, tailored educational materials, and follow-up calls or mailings to increase trust in the patient–provider relationship.…”

“…Relative to online notification of CRC screening, Lafata et al (2022) found that only 28% of adults have an activated portal account through their primary care physician. In addition, Black adults are substantively and significantly less likely to have an active portal account, which limits the usefulness of this tool for delivery of screening reminders to this population.…”

Filling the Gap Between Potential and Actual Usefulness of Electronic Health Record (EHR) Data as Patient-Level Evidence

“…Above and beyond the intervention’s impact assessment, reported findings stress how the advantages afforded by developed EHR systems, in terms of embedding patient-facing interventions within clinical practice, are still in part offset by a programme effectiveness diminished by the uneven coverage of EHR tools of the target population. 4…”