Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity

Abstract

Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

Keywords: cancer screening; health information technology; medical informatics; practice guidelines; uterine cervical cancer.

FIG. 1.

Project timeline. It depicts the project timeline and associated activities for the multiyear CCSM CDS initiative. The team has completed Year 1 activities and is currently in Year 2 of the 3-year effort. Define CDS (Year 1): conduct environmental scan, delineate CDS definitions, test fixtures and software, and produce implementation guide. Pilot CDS (Years 2 and 3): secure pilot partners, integrate with EHR, and evaluate CDS effectiveness. Quality Measures (Years 2 and 3): prototype companion electronic clinical quality measures. Adoption (Year 3): communicate, disseminate, message, and share project updates. CCSM, cervical cancer screening and management; CDS, clinical decision support; EHR, electronic health record.

FIG. 2.

Environmental scan components. The environmental scan included the eight components shown in Figure 2 and considered CCSM guidelines, CCSM CDS tools currently in use, existing clinical workflows, patient needs and preferences, and aspects of patient care that could best be enhanced by CDS: Evidence Review: Authoritative evidence for screening and management guidelines; Current Clinical Practices: Common ways CCSM are done today, and how the guidelines are currently followed in clinical practice; Patient Experiences: Experiences with respect to women's cervical health, and how can the patient experience be improved with CDS; EHR and Related Capabilities: CDS capabilities supported by EHRs today and any specific support for cervical cancer; Anatomic Pathology and LIS: Content and format of test results (e.g., Pap, HPV, and biopsy) as well as how LISs can integrate with EHRs; Information Standards: Interoperability standards for representing health information, pathology results, CDS and potential gaps; Quality Measures: Quality measures for screening or management of cervical cancer. HPV, human papilloma virus; LIS, Laboratory Information Systems.

FIG. 3.

Conceptual clinical workflow with CDS working in conjunction with EHR. It illustrates the workflow and interaction with the CCSM CDS in clinical setting: Patient information flow is shown in green. The Patient Health Portal represents patient-facing interactions with their health data, and could utilize web access, a mobile app, or messaging services. Clinician information flow is shown in blue. The clinician interacts with the CDS service, which queries the EHR server for patient data. Screening and treatment providers are shown in brown. These represent laboratory services, cancer specialists, surgeons, or other specialized care providers. The results of all health actions are recorded in the EHR server. These results can further inform the CDS service, other clinicians, and the patient health portal.