Scheduling the Screening Study
CCT: Any provider can order and schedule an LCS study. They are ordered and scheduled in a decentralized manner. The EHR includes a best practice advisory which triggers consideration of an LCS study based on age and smoking history. Once an exam is ordered, the eligibility criteria are then assessed by radiology in a centralized way. If the criteria are not met, the radiologist will query the ordering provider and either cancel the study or change it to a diagnostic CT where appropriate. Each office has a different workflow for scheduling the study with radiology. In most offices administrative staff or medical assistants obtain prior authorization for the exam where necessary and schedule the study following approval.
EMH: We started off having orders for LCS routed through central scheduling and switched to an EHR-based distributed model. The distributed EHR model is only as good as the vendor and IT implementation team allow it to be, however, and we are progressing back towards a centralized model. In our system, a central scheduling model seems to offer us the best chance of order success. I anticipate this will change again when we complete a system wide EHR migration project in the near future.
SR/BM: All LCS exams are scheduled by one of our two program coordinators. LCS exams are not scheduled through central scheduling due to potential pre-authorization requirements.
CF: In general, primary care physicians and pulmonologists enroll patients into the screening program. All orders for LCS studies are processed through our LCS program coordinator and vetted for appropriateness. To the extent that our EHR is able, patients who may qualify for LCS are identified and their provider is notified. The LCS study is ordered through the EHR as “lung cancer screening CT.” We originally had the order as “Low dose CT for lung cancer screening” and physicians would use the order for non-eligible patients because they liked the idea of low-dose. In addition, when ordered, a box comes up where the ordering provider has to check boxes to confirm eligibility criteria, confirm that they have performed and documented shared decision making, and confirm that they are enrolling the patient in the LCS program. The order is transmitted to radiology and the LCS program. The LCS program navigator confirms insurance coverage details, contacts the patient, confirms their understanding of out of pocket costs, and schedules the CT.
KS: The Vanderbilt University Medical Center referring providers may order the LCS study as they order other imaging tests and patients are then scheduled by the imaging center. We only perform these studies at our outpatient imaging facilities, which allow us greater control of scheduling (do not have to involve the main hospital ordering system). The imaging center schedules a consult appointment with the radiology nurse practitioner immediately prior to the LCS appointment. This allows the nurse practitioner to confirm eligibility criteria and perform a shared decision-making visit if necessary.
CL: Program navigators, after reviewing for initial and continuing eligibility, will send an EMR in-basket message to the healthcare provider with a reminder of the patient’s eligibility, so that timely orders can be activated by the provider. It would be equally important to provide ordering providers prompts or reminders when patient eligibility has ended, so that imaging beyond the guidelines does not occur.
CCT: Any office can schedule an LCS study once an order has been placed. Radiology will then review the eligibility criteria to ensure that the patient is eligible. Reporting requirements are maintained through the EHR within the ordering fields with mandated questions regarding shared decision making and smoking cessation counseling.
RSW/KS: Our program is a hybrid. There is the option of either decentralized referral (PCP conducts SDM and places LCS order) and ordering of the study or centralized referral (PCP refers patient to an LCS / Pulmonary Nodule clinic for SDM visit and decision whether to proceed with screening; if yes, the sub-specialty clinic provider places LCS order).
MKG: LCS studies are ordered by primary care providers and pulmonologists using a standardized order set in the electronic health record. Providers are required to check boxes to confirm that the patient is asymptomatic, meets eligibility criteria, has undergone shared decision making, and has been referred for tobacco cessation treatment (TST), if a current smoker.
JM: LCS studies are ordered through a trigger in the patient’s electronic medical record (EMR) which triggers a clinical reminder for their physician to order a CT chest screening. The clinical reminder is based on patient’s age and smoking history. If a physician chooses to order a CT chest screening, they then perform a shared decision-making session with the patient to discuss the risks and benefits of CT chest screenings. Once the exam is ordered, the patient can call radiology to schedule their exam.
CGS: The VA Portland Health Care System is a centralized program where SDM and orders are performed by dedicated LCS program personnel.
PM: Any clinician in our health system can place an order for a consult to our LCS program. Our program administrator screens the order for patient eligibility. If the patient is eligible an order for the SDM visit and coordinated CT scan is placed, then signed by our program navigators.
SR/BM: We created an LCS request order that has no CPT code attached (and therefore cannot be scheduled/billed) that we ask physicians to place when they are ordering a screening exam. This request also falls onto a work queue and is changed to the correct order by a program coordinator based on the patient’s most recent exam.
GM: We have an order that requires the completion of criteria eligibility questions. It then goes to a work queue for review by our NP who places the actual order.
CCT: Any LCS order can only be placed in the EHR after the provider completes questions related to symptoms, shared decision making, and smoking cessation counseling for eligible patients. These are sent to radiology and screened to make certain the patient meets criteria prior to the study being performed. In the ordering process the baseline vs. follow-up examination are options and this is verified centrally in radiology. The order is changed where necessary.
EMH: No system is perfect in this respect. We use a mix of distributed and central ordering with downstream checks to try to maximize adherence to recommended screening criteria. A robust IT implementation including hard stops for adherence to individual criteria is very helpful in this respect.
SR/BM: Yes. Non-CMS patients will also require pre-authorization.
CF: Yes, in particular some patients with private insurers have a large co-pay as some plans are grandfathered and are not obligated to fully cover LCS despite its Grade B recommendation. We try to identify the patient cost and share this with them prior to the scan being scheduled.
CCT: Yes, all patients will have an insurance pre-authorization where needed and any large co-pay or denial of coverage would be relayed to the physician and the patient prior to scheduling the exam.
EMH: An annual lung cancer screen should not be considered a “follow up” exam. Annual rescreening is the expected result for most patients undergoing LCS. Our EHR currently makes no distinction between first and subsequent lung cancer screens; annual exams are simply ordered as LCS. For short-term follow-up chest CT exams (three-month or six-month, as directed by Lung-RADS™ category), the exam is typically ordered as a non-contrast chest CT at the appropriate interval. In the exam protocoling stage the technical parameters for the exam are prescribed to be concordant with best practices for LCS and nodule follow-up.
CCT: In terms of follow-up examinations, ensuring LCS exam vs. other forms of CT scanning is challenging. Radiology reports should indicate which form of examination is appropriate for follow-up based on the initial findings. If there are no findings, the patient is returned to annual LCS exam. In our EHR, the orders specify initial low-dose screening or follow-up low-dose screening. All screening orders are reviewed for appropriate study classification in radiology prior to the exam being completed and changed if necessary.
SR/BM: We have a separate section of our database to help catch incorrectly ordered exams before the patient arrives so we can fix them if necessary. We have an alert board that, among other things, informs us of patients in the screening program who have a regular (not screening-related) chest CT scheduled within the next two weeks. If this CT was incorrectly ordered and should be either a screening exam or a follow up to a screening exam, we can make the change at that time so the exam will be tracked appropriately.
CF: All LSC exam reports are transmitted to LCS program in addition to the ordering provider. The LCS program physician reviews all reports and confirms appropriate follow-up (annual or otherwise) with respect to lung with the program navigator. The program navigator enters an alert into the EHR to be trigger a few weeks prior to scan due date. Eligibility for the LCS exam is reconfirmed prior to the follow-ups being ordered.
BM/SR: Prior to a patient’s annual screening exam, our database searches the patient’s record for any chest imaging (CTs or chest chest radiographs) the patient has had in the 12 weeks leading up to the screening exam. Often times chest imaging is ordered due to upper respiratory symptoms so this can cue us in if the patient is symptomatic. Further, patients receive a reminder phone call two days prior to their appointment where they are reminded that they should reschedule the exam if they have new or worse cough or shortness of breath, unintentional weight loss, or are coughing up blood.
RSW/KS: Defer to PCP (or other ordering provider) to ensure patient remains an appropriate candidate for screening.
CF: LCS program coordinates annual follow-up. Patients receive reminder letter and are called by LCS program navigator to confirm appointment. Patients are screened for symptoms by navigator using symptom screen form at time of call. Any symptoms are reviewed with LCS program doctor prior to scheduling scan.
GM: We have a script that is given to the program coordinator. She performs a basic screen at the time of the appointment reminder call.
DTC/CCT: As a part of the electronic health record order, there is a built-in hard stop attestation that the patient does not have symptoms. If that hard stop attestation is not completed, the order cannot move forward. Additionally, patients are queried at the time of their screening study as to any respiratory symptoms. If the patient is symptomatic, the ordering provider will be notified and the study may be changed to a diagnostic rather than screening CT; the study may alternatively be deferred if the symptoms are believed to be due to a URI, etc.