Preventive Care - Key Activity 12

KEY ACTIVITY #12:

Develop and Implement a Follow-Up System for Those Who Have Been Screened

 
This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement.

Overview

This activity outlines the importance of communicating screening tests results to patients and initiating timely follow-up on positive results.

Screening for colorectal, breast and cervical cancer is performed to detect cancer early and to enable early treatment to prevent advancement of the cancer and improve survival. Patient safety is advanced when providers use a closed loop strategy to communicate results. Positive screening test results – evidence of cancer or suspicions of cancer [1] [2] – show that timely follow-up is optimal and patients prefer that positive results be communicated swiftly and verbally.

California does not require a provider’s order for a person to obtain a screening mammogram, but it does require that the mammography provider notify both the patient and their healthcare provider of the results of screening mammography. Consequently, the follow-up system should include a process for receiving mammography results, communicating with the patient following the results, and implementing a conversation with the patient about the need for further follow-up if the results are positive or suspicious.

Low-income and minority populations have higher death rates from breast, cervical and colorectal cancer and experience inequities in access to care to address cancer. When patients agree to undergo screening tests, timely communication of test results improves rapid follow-up of positive tests and supports effective communication with the healthcare system. When the patient understands the test result and its meaning and they are given the opportunity to understand the implications of the result, they are more likely to engage in follow-up.

Follow-up of test results, positive or negative, empowers patients with information that supports their ability to make decisions about future screening or diagnosis. While many systems have patient portals, active notification of test results allow patients with significant social needs to understand the implications of those results. Patients can then access supportive services that improve their ability to follow through with further care when screening tests are positive.

Most EHR platforms allow for the identification of outstanding orders and referrals. When an order or referral is placed, it remains open until that service is completed. Leveraging a report on open orders and referrals for this intervention will allow for reconciliation of those orders. Outreach to patients will allow for determination of the status of the test or referral, provide an opportunity to remind the patient, get feedback on their intention to follow through, or allow for reconciliation with the testing or referral site.

Where possible, the use of external data (e.g., claims, HIE data) can be leveraged to minimize individual patient outreach efforts. The use of patient engagement technologies can also be leveraged as indicated.

Action steps and roles

1. Develop or refine your practice’s screening follow-up protocol.

Suggested team member(s) responsible: Panel manager and their designee(s).

The multidisciplinary team will start by identifying the person or persons who will be responsible for creating a protocol for follow-up of screening test results. In many cases, this will involve the panel manager and other members of the care team. This team will create a protocol that allows care team members to provide a prompt response and to notify the PCP when a test result is positive. This process must use closed loop communication where every test result is sent, received and acted upon in a timely manner in accordance with the practice’s protocol.

At a minimum, the protocol will identify:

  • Which types of screening tests will require health center follow up, such as fecal-based testing and Pap smears.
  • Who (specifically) will provide the follow-up. For example, colonoscopy follow-up is typically provided by the clinician who conducts the colonoscopy.
  • How the follow-up will occur, the timing of the follow up, and the language in which to communicate the results, which may be constructed through the EHR. For example, the team may elect that normal screening test results will be communicated by mail while positive results will be followed up through a telephone call from a clinician or a direct office visit to enable the patient to ask questions and receive guidance.

How results are communicated is critically important. A Preventive Medicine Reports article in 2019 references a systematic review of communication methods used to deliver results of cancer screening. They found that several aspects of the communication were important:

  • Timeliness of the report.
  • Accuracy.
  • Visual support.
  • The ability to ask questions.
  • The privacy of the results.
  • Managing expectations.

2. Implement your practice’s screening follow-up protocol.

Suggested team member(s) responsible: Care team member indicated in the practice’s protocol.

  • Share results and initiate follow-up steps, if needed. This process must use closed loop communication where every test result is sent, received and acted upon in a timely manner in accordance with the practice’s protocol. The care team member tasked with screening test follow-up will create a communication to the patient.
    • Normal screening results may be shared in writing or in a follow-up visit with the patient. Patients should be informed when the next screening is due.
    • Abnormal or suspicious findings should be communicated by telephone call or in an office visit directly with the provider.
      • When the patient cannot be located or a visit is missed, there should be a system to increase attempts to reach the patient with the results.
      • If the patient appears in the health center, abnormal results should be flagged in the record and communicated with the patient.
      • Attempts to reach the patient and share the results should be documented in the record.
  • Discuss the results with the patient. Clinicians should be prepared to respond to discuss the implications, invite patient questions, discuss the need for and type of follow-up, and be ready to offer the team’s assistance in organizing the follow-up.
    • Abnormal results should be explained to the patient and allow an opportunity for the patient to ask questions. Guidance from the National Cancer Institute and CDC[3] can help to explain the results to the patient and assist them in understanding the recommended follow-up to the Pap smear based on the Pap smear result.
    • Follow-up of the abnormal results should be scheduled as soon as possible with the direct assistance of practice staff.
  • Patients should be offered care coordination or supportive services to enable them to address social and other needs that interfere with their ability to follow through on further care.
  • Maintain contact with the patient to help ensure follow-up. The care team should maintain contact with the patient to help ensure that they engage in any recommended follow-up and that they continue to receive any recommended follow-up, if the screening test was positive, and future screening(s). This can be accomplished by telephone, electronic reminders or mailed reminders.
  • Document the result. The team member who initiates the communication of the test result documents the result, communication of the result, and the recommended follow-up in the EHR.

Example workflow

Based on the type of screening test and your practice’s screening protocols, your workflow may differ.

  1. Results are communicated to the practice.
  2. Per the practice’s protocol, test results may be divided into “within normal limits,” “positive,” "suspicious” or “abnormal.”
    • If the screening test was performed by an outside provider, such as a mammography center or a surgical center, the screening entity may provide the results to both the patient and to the practice.)
  3. Results are communicated to the patient.
    • Normal results are communicated to the patient via telephone, letter or the EHR portal or in person.
    • Abnormal, positive or suspicious results trigger direct communication with the patient to make an appointment to discuss the results with the PCP or, per protocol, with another team member designated to follow up.
      • If the practice uses a portal to identify test results, the practice will need to determine if and how positive results are posted in the portal to enable patients to obtain information as soon as possible.
  4. During the visit, the PCP discusses the results with the patient, explains the recommended follow-up and responds to the patient’s questions.
    • Where indicated, a follow-up appointment is initiated with a practice provider.
    • Where indicated, an appointment is initiated with an outside provider and the appointment is shared with the patient.
      • The referring clinician initiates a referral letter to the outside provider to provide information about the patient.
  5. A practice team member may be tasked to follow up on appointments to identify if appointments were kept.

Implementation tips

  • Use the EHR to support standardizing language for negative test results (within normal limits) in electronic or mailed communications.
  • Recognize that communicating positive or suspicious results may result in anxiety on the patient’s part. Therefore, time the communication so that the practice can be reached by telephone when the patient is likely to receive the results.
  • Offer patients an opportunity to discuss test results by phone or in an office appointment, even if the result is negative.
  • Follow up on abnormal results if the patient is not easily reached by using community liaisons and adhering to Health Insurance Portability and Accountability Act (HIPAA) guidelines.

Evidence base for this activity

Williamson S, Patterson J, Crosby R, Johnson R, Sandhu H, Johnson S, et al. Communication of cancer screening results by letter, telephone or in person: A mixed methods systematic review of the effect on attendee anxiety, understanding and preferences. Preventive Medicine Reports. 2019 Mar;13:189–95.

Endnotes

  1. Doubeni CA, Gabler NB, Wheeler CM, McCarthy AM, Castle PE, Halm EA, Schnall MD, Skinner CS, Tosteson ANA, Weaver DL, Vachani A, Mehta SJ, Rendle KA, Fedewa SA, Corley DA, Armstrong K. Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium. CA Cancer J Clin. 2018 May;68(3):199-216. 
  2. Sansoni M, Tagai EK, Lapitan E, Wen KY, Xu J, Belfiglio A, Hudson SV, Kohler RE, Hernandez E, Miller SM. Development of a text message-based intervention for follow-up colposcopy among predominately underserved Black and Hispanic/Latinx women. Cancer Causes Control. 2022 Jun;33(6):861-873. doi: 10.1007/s10552-022-01573-y. Epub 2022 Mar 25. PMID: 35334016; PMCID: PMC9516784. 
  3. National Cancer Institute. HPV and Pap Test Results: Next Steps after an Abnormal Cervical Cancer Screening Test - NCI [Internet]. www.cancer.gov. 2022. Available from: https://www.cancer.gov/types/cervical/screening/abnormal-hpv-pap-test-results