According to the American Cancer Society, “Lung cancer is the leading cause of cancer death among both men and women.” But there is hope. Low-dose CT scans can help detect lung cancer at its earliest stage, when it’s most treatable. The challenge is to identify those patients at high risk and encourage them to get screened.
Starting in May 2017, Compass Medical, a comprehensive healthcare organization south of Boston, rolled out a lung cancer screening program and developed work flows in its electronic health record (EHR) to make it easy for providers to support the program.
The guidelines around offering a low-dose CT scan in high-risk populations have been progressively developed since 2011, explained Michael Myers, M.D., Compass’ chief medical officer. The Center for Medicare and Medicaid Services (CMS) covers the CT scans for a population of patients between 55 and 77 who meet certain heavy smoking criteria over many years, were asymptomatic and had no prior chest CT in the preceding 12 months. “When a patient meets those critieria, they are thought to be in a high-risk pool. Those are the folks you want to screen,” Myers says. The challenge is finding those people.”
Setting up screening programs for breast, cervical or colorectal cancer is easier, because it basically involves age or sex cutoffs. “But when you are adding smoking status and current smoker and no symptoms and all these other factors, that is where our EMR system really helped,” he says.
Christine Machado, Compass’ EHR manager, says her team created a template in the EHR with the guided questions for a medical assistant to ask to help determine eligibility. They also created the order set for shared decision making and radiology referrals. She adds that the EHR team transformed the Center for Medicare and Medicaid Services lung cancer screening eligibility requirements into a practical and complete clinical operational workflow for recording these data points within the EHR.
If a patient satisfies those criteria, the assistant tells the physician this patient is likely to benefit from the low-dose CT screening program. “That is how over 18 months we have been able to identify all the patients in our practice who are likely to need screening,” Myers says. “Those patients then have a shared decision-making visit. The ordering provider will sit and explain the risks, and benefits of screening and not screening, and have the patient agree to have a screen or to say they understand the risks but are not ready to have a scan yet.”
Once patients are identified as qualified and agreeable to this specific treatment plan, the low-dose CT order is placed in the patient’s EHR with just two clicks. From there, the radiology scheduling department is able to locate orders and contact the patient for scheduling a testing date. This ensured the patient’s screening documentation was defined, the provider documentation was shared and the decision making was completed. The radiology team was then able to confirm the rigorous pre-requisites were documented accurately and associated to the order prior to performing the test.
Compass also has created a care pathway with a group of thoracic surgeons. “If you have one of these suspicious nodules, we get you to see a surgeon within three to five days,” Myers says. “Our job in primary care is to find these asymptomatic patients in the general population and convince them to get scanned, and get them referred quickly. We then hand the baton to the proper specialist once we have done our job at identifying the patients at risk.”
Since May 2017, the medical group has identified 1,800 patients eligible for the program and 1,000 of those patients received a low-dose CT scan. Of those 1,000 patients that Compass Medical has scanned, it has confirmed 13 lung cancers, diagnosed five incidental non-lung cancers and has 43 unique patients with suspicious nodules found through the screening who it is tracking closely. Compass Medical was recently named a “Screening Center of Excellence” by the Lung Cancer Alliance.
Despite the clinical guidelines from the U.S. Preventive Task Force, Compass noted that less than 3 percent of eligible patients get a low-dose CT screening because primary care offices don’t have the extensive capability, referral activity or resources to support a program like this. Medical groups do not generally launch, manage and conduct their own lung cancer screening programs. Most medical groups don't have an ACR-accredited CT scanner or a radiology group embedded in the practice, so most lung cancer screening programs are developed at hospitals. “But the problem with a hospital-based program is that it is often separate from the referring primary care doctors, so it is actually better to have this located close to the physicians working with the patients,” Myers says. “We are lucky to have the EMR system, and the ability to identify and scan these patients.”
In 2019, Myers claims, it is just good medical practice to create a program or refer patients to a program where they could be screened. “This is now the community standard and scientifically accepted practice,” he said. It takes organizational commitment and a champion to think through all the elements of a screening program. His advice for other practices looking to create such a program? “You can’t let the perfect be the enemy of the good,” Myers says. “Start where you are with the patients in your practice.”