EHR Alerts: A Real Bummer for Colonoscopy Adherence, Study Suggests

Posted by Jeremy Guttman on 6/16/16 6:07 PM


As the CDC sounds the alarm to increase awareness for colorectal cancer screening, primary care practices find that their EHRs can’t support the task of getting patients to complete colonoscopy referrals. In addition to the CDC, there is a growing focus by medical societies, advocacy organizations and media personalities like Katie Couric to ensure that adults over 50 get referred for colonoscopies to detect and prevent colorectal cancer. Awareness initiatives are critical because half of all patients referred for colonoscopies fail to complete the procedure.1

Researchers at the Perelman School of Medicine at the University of Pennsylvania tested EHR active choice reminders2 as a way to prevent colon cancer. The reminders barely made a difference — improving colonoscopy completion rates by a nominal 3.5% compared to a control group.

Alternative solutions to improve colonoscopy referral adherence are vital because up to 90% of colorectal cancer deaths are preventable with early detection.3

Given these points, one possible strategy to improve adherence is to closely manage and track referrals electronically, which leads to appointments being accepted and scheduled by specialists over 85% of the time.4

In the EHR alerts study, published in Healthcare: The Journal of Delivery Science and Innovation, care teams were required to make a choice about patient colonoscopy appointments in the EHR system before they could continue using the EHR. They were automatically prompted to choose to "accept" or "cancel" for colonoscopy orders.

The “active choice” workflow change was considered a combination of:

  1. Interrupted alert for clinical decision support - because it popped up automatically when a patient was overdue for a colonoscopy
  2. Forced choice for clinical decision support - because the practitioner couldn’t continue without choosing one of the options

Active choice is a concept that comes from the field of behavioral economics. With active choice there is no default  decision makers are required to make a choice.5

Notably, the study in Healthcare found that active choice prompts in EHRs moderately increased the number of colonoscopy referral orders by 11.8%. But there was only a 3.5% increase in colonoscopies that were actually completed. Overall, the results demonstrate the giant chasm between physicians simply telling patients to get colonoscopies and patients actually getting them. Without an electronic solution to manage and track referrals, over 70% of the new colonoscopy referral orders attributed to EHR alerts became failed referrals.2

Study conclusion: focus beyond the EHR


In order to increase colonoscopy screening rates, the study asserts that patients need to be more engaged in their care. Additionally, there is a need for better patient-focused interventions, such as patient direct mailings, to get patients to complete screening tests after the tests are ordered. Cloud-based health IT software products that pull information from EHR systems, such as high-performance referral management, are another type of intervention that accomplishes increased appointment adherence goals and helps primary care practices focus beyond their EHRs. It enables care collaboration so that important referral information is shared between PCP and specialist offices. Therefore, the referral status of every patient can be tracked at every step of the way. Providers are empowered to intervene with patients at the right time to make sure patients go to their appointments.

Because this study tested EHR alerts, it’s worth noting that many physicians find EHR alerts annoying and distracting when there is no ability to edit or filter them. On average, physicians spend more than an hour a day dealing with EHR alerts. Too many alerts overwhelm practitioners and lead to a phenomenon called alert fatigue where clinicians ignore safety notifications up to 96% of the time. Alert fatigue increases the chances that a physician will miss patients' test results6 and cause a preventable health disaster such as an allergic reaction or deadly drug interaction.

In contrast to EHR alerts, high-performance referral management offers a vastly superior way to increase colonoscopy completion rates. For the first time, practices can see which patients are getting recommended specialist appointments, which ones aren’t, and how long the referral process takes at every step of the way.

Specialists reach out to patients instead of patients having to reach out to specialists so that appointments are accepted and scheduled by specialists 85% of the time.4

PCPs don’t have to waste time calling specialist offices to double-check if a patient made it to an appointment or to ask for a specialist consult report, and 70% of specialists attach and send consult reports to successfully close the referral loop for every single referral.4 If a patient doesn’t make it to an appointment, the PCP will know about it and can quickly follow-up with the patient to further encourage them to make the recommended appointment.

To learn more about how high-performance referral management improves the colonoscopy referral process, read our post: So Many Colonoscopy Referrals, So Few Appointments.


1 Journal of General Internal Medicine |

2 Healthcare |

3 Cancer Epidemiology Biomarkers & Prevention |

4 Internal Treatspace metrics

5 Journal of Consumer Psychology |

6 JAMA Internal Medicine |


Topics: Coordinated Care, Referral Management, Closed-Loop Referrals, Referral Adherence