For Patients at High Risk of Hereditary Cancer, Automated Alerts in EHRs May Increase Rates of Genetic Testing, But Implementation Barriers Impede Their Use

As many as one in 10 cancers may result from an inherited mutation, and national guidelines from multiple societies support referral for genetic counseling and testing for patients with a history that increases risk of having a hereditary cancer syndrome. Nevertheless, despite efforts to increase rates of genetic assessment by educating oncology care providers and patients about these syndromes, only 1% to 10% of patients with the most common hereditary cancer syndromes have been identified since BRCA1 was cloned in 1994.

Incorporating automated alerts into the electronic health record (EHR) may help increase this identification rate. These alerts can be used to remind clinicians to follow evidence-based recommendations during visits with patients and were shown to increase the rate of compliance with such recommendations by 5% to 10%.

To increase referrals for appropriate genetic counseling and testing, researchers at the University of Arkansas for Medical Science in Little Rock, AR, launched a pilot program that included an automated alert named Best Practice Advisory in EPIC EHRs to flag patients with a personal or family history that indicated referral to cancer genetics was appropriate (JCO Oncol Pract. 2022; Published online March 22. doi:10.1200/OP.21.00641). 

However, because EPIC was unable to automatically gather the data needed to determine the appropriateness of such a referral, staff had to complete a questionnaire to do so. This questionnaire incorporated branching logic to sub-questionnaires to identify appropriate patients for referral.

The researchers then educated oncology care providers about the pilot program and implemented the Best Practice Advisory with the resources needed to support its use.

Upon completion of the pilot program, the researchers noted that, although initial use of the alert was high, interest in it rapidly tapered. During the 9-months of the program, the questionnaire was completed for 7% of >32,000 encounters and 15% of patients, and cancer genetics referrals increased by 96% (P<0.001). In 19% of cases, referrals were made in response to the Best Practice Advisory. The remaining referrals were made through another mechanisms.

After interviewing key stakeholders, the researchers discovered that the alert concept was generally accepted; however, several barriers existed to completion of the questionnaire, including pressure to place patients in exam rooms quickly and poor support of the program by some oncology providers.

“The [Best Practice Advisory] was designed to keep firing until addressed and then repeat annually,” wrote the study report’s lead author, Kristin Zorn, MD, and colleagues. “However, since 92.7% of questionnaire completions happened after the first two alerts, repeated alerts beyond that appear to have diminishing returns and may contribute to alert fatigue.” 

“These results suggest that provider engagement and [alert] fatigue are significant obstacles to acceptance of a new automated alert,” Dr Zorn and colleagues concluded. “Despite interest in a tool for cancer genetics, the demand on clinical time for this complex [alert] was poorly tolerated…. We have opted not to continue the genetics [Best Practice Advisory] until the EHR can extract the details needed to generate the referral recommendation without requiring staff involvement in a questionnaire.”