Provider Perceptions of an Electronic Health Record Prostate Cancer Screening Tool

Abstract

Objectives We conducted a focus group to assess the attitudes of primary care physicians (PCPs) toward prostate-specific antigen (PSA)-screening algorithms, perceptions of using decision support tools, and features that would make such tools feasible to implement.

Methods A multidisciplinary team (primary care, urology, behavioral sciences, bioinformatics) developed the decision support tool that was presented to a focus group of 10 PCPs who also filled out a survey. Notes and audio-recorded transcripts were analyzed using Thematic Content Analysis.

Results The survey showed that PCPs followed different guidelines. In total, 7/10 PCPs agreed that engaging in shared decision-making about PSA screening was burdensome. The majority (9/10) had never used a decision aid for PSA screening. Although 70% of PCPs felt confident about their ability to discuss PSA screening, 90% still felt a need for a provider-facing platform to assist in these discussions. Three major themes emerged: (1) confirmatory reactions regarding the importance, innovation, and unmet need for a decision support tool embedded in the electronic health record; (2) issues around implementation and application of the tool in clinic workflow and PCPs' own clinical bias; and (3) attitudes/reflections regarding discrepant recommendations from various guideline groups that cause confusion.

Conclusion There was overwhelmingly positive support for the need for a provider-facing decision support tool to assist with PSA-screening decisions in the primary care setting. PCPs appreciated that the tool would allow flexibility for clinical judgment and documentation of shared decision-making. Incorporation of suggestions from this focus group into a second version of the tool will be used in subsequent pilot testing.

Keywords

shared decision-making - prostate cancer - screening - decision support - electronic health record - oncology - clinical decision support

Background and Significance

All guidelines recommend that prostate-specific antigen (PSA) screening be an individual decision, occurring after shared decision-making (SDM).[1] [2] [3] [4] However, engaging in SDM is a challenge for primary care physicians (PCPs) who work under time constraint. PSA screening is a complex topic, and PCPs admit poor knowledge.[5] Furthermore, national recommendations vary year-to-year and between guideline organizations. For instance, the United States Preventive Services Task Force (USPSTF) recommended against PSA for all men in 2012 but then advocated for SDM for men ages 55 to 69 years in 2017.[6] In contrast, the National Comprehensive Cancer Network (NCCN) recommends regular screening for men ages 45 to 75 years but starting at 40 years for men at increased risk.[7] The NCCN guideline is also complex in that the screening frequency is determined by a man's age and PSA level (e.g., every 2–4 years if PSA is <1 µg/L or every 1–2 years if PSA is between 1 and 3 µg/L), requiring PCPs to recall an algorithm to individualize screening recommendations for patients.

Adding to the complexity of the SDM process that PCPs should follow is the recommendation from the International Patient Decision Aids Standards Collaboration to use decision aids that prioritize completeness of information.[8] As a result, most available tools are comprehensive,[9] and there is clear evidence that PCPs do not engage in SDM with patients.[10] [11]

Objectives

We sought to develop and implement a clinical decision support (CDS) tool for SDM and PSA screening in primary care that leverages the electronic health record (EHR) and can be used at the time of consultation. We hypothesized that effective dissemination of a rational approach to PSA screening and SDM, utilizing the EHR, would be more acceptable in helping to guide PCPs' decision-making than passive dissemination of paper-based clinical practice guidelines.[12] [13]

The aim of this study was to conduct a focus group to assess PCPs' attitudes toward PSA-screening algorithms and perceptions of using CDS tools, and to assess the feasibility of implementing such a tool in clinic. We suggest that widespread failure to follow well-accepted PSA-screening guidelines is because the algorithms are complex, and PCPs lack the tools to efficiently implement the SDM process.

Methods

Development of the CDS Tool

First, we assembled a multidisciplinary, collaborative research team consisting of experts in primary care, urology, behavioral economics, epidemiology, biostatistics, and health informatics. Next, we established partnerships with Brigham and Women's Hospital (BWH) Primary Care, a large-scale PCP network in Boston, and the EHR vendor Epic Systems Corporation (Epic, Verona, Wisconsin, United States) to develop the interface for the electronic CDS tool. There was uniform consensus within the research team to utilize the PSA-screening algorithm for early detection as proposed by the NCCN.[7] Unlike the United States Services Task Force 2018 guideline which gives no guidance on the re-screening interval, the NCCN guideline provides an algorithm for this (the frequency of testing which depends on the man's age, health, and prior PSA levels, see [Supplementary Appendix]) which were incorporated into the tool. In developing the intervention, we leveraged a negotiation theory framework that we have previously developed and tested at Memorial Sloan Kettering Cancer Center (MSK), utilizing appropriate framing techniques derived from behavioral economics principles, developed in collaboration with Harvard Business School.[14] [15] These principles have been demonstrated to impact medical decision-making[16] [17] and were incorporated in the narratives in the tool ([Supplementary Appendix]). In short, we instituted the guideline-recommended practice as the default button (e.g., “Keep order” or “Remove order”); leveraged social proof by referencing what most PCPs would do in a given clinical situation; shifted the reference point by focusing on other health promotion efforts for older men; and required PCPs to document override reasons, accountable justification.[18] [19] [20] [21] A script for facilitating SDM conversations about PSA screening was also embedded within the CDS tool and followed a Simple Schema for informed decision-making, details of which have been described previously.[10] In brief, the Simple Schema presents 10 simple talking points to PCPs in three sections: four key facts about prostate cancer and screening, three key take-home messages, and two options facilitating the discrete decision (yes/no to screening).[10]

Description of the Proposed Intervention

The CDS tool is described in detail in the [Supplementary Appendix]. In brief, the tool comprises four components: (1) the NCCN guideline for early detection of prostate cancer, a risk-stratified screening algorithm[7]; (2) a provider-facing tool for SDM (Simple Schema[10]); (3) three best practice advisories (BPAs) for: eligible patients (45–75 years), patients who are too young for prostate cancer screening (<45 years), and patients who are too old for prostate cancer screening (>75 years); and (4) a health maintenance module, allowing PCPs to schedule the next interval for PSA testing, for example, every 1 or 2 years depending on the previous date and result of the PSA test.

Recruitment and Study Sample

Invitations to participate in the study were sent via e-mail to all PCPs in the BWH network from the Associate Medical Director. The first 10 participants who expressed interest verbally consented to the study.

Focus Group

The focus group method was chosen to obtain both the individuals' and collective group's views of PCPs regarding PSA-screening and CDS tools. We suggest that the focus group format would promote interaction, diversity of opinions, and an open conversation among PCPs about their experiences with PSA screening and perceptions of CDS tools integrated into the EHR. Standard procedures for conducting focus groups were followed.[22] The focus group was held in September 2018 in a conference room at the BWH in Boston and lasted a total of 3 hours that was split in two parts.

First, participants received written and verbal information about the aims and ethics of the study, with an opportunity to ask questions about participation. We subsequently distributed an anonymous study-specific paper survey to assess participants' baseline preferences and views about PSA-screening guidelines and practices. We then walked the PCPs through each step of the PSA-screening algorithm and asked open-ended questions to obtain feedback regarding the acceptability of the proposed CDS tool. We sought feedback on: which risk factors participants assess when ordering a PSA test (e.g., family history, race, and lower urinary tract symptoms); which screening test they use (PSA and/or digital rectal examination [DRE]); age they consider important when starting PSA screening; age they consider important when stopping screening; frequency of PSA testing; information on outlier patients; how they have SDM conversations; information they use for repeating an elevated PSA level; and when they would refer men for prostate biopsy.

Second, we presented the PCPs with the mock-up 1.0 version of the CDS tool, including various alternative “pop-up alerts,” narratives, and order sets, and asked them whether they would act on the information presented following the algorithm, and whether they found the language supportive or offensive. We asked the PCPs open-ended questions to obtain qualitative feedback on what they liked and disliked about the algorithm and solicited suggestions for improvement. Thus, the PCPs were actively involved in designing and modifying the tool.

Data Collection

A technician audio-recorded the focus group. The digital recordings were sent to an outside transcription service and transcribed verbatim. A study coordinator was present during the focus group and took notes on key comments by participants and impressions of the meeting and entered data from the surveys into a database.

Analysis

To understand participant feedback about a specific topic, i.e., in this case for the development and refinement of a CDS tool, we used Thematic Content Analysis.[23] The transcripts and field notes were analyzed to develop codes, categories, and themes inductively. No qualitative data analysis software was used. One study investigator reviewed participants' quotes which were cut and pasted from the transcripts into a separate Word document, and categories and themes were developed from immersion of data. In discussion with a second independent research assistant who was not involved in the study design or conduct of the focus group, these categories and themes were then conceptually refined to develop superordinate (higher level) themes, which were discussed with the research team to ensure the themes accurately reflected the participants' views and perceptions. Survey responses were analyzed descriptively using the statistical software Stata (StataCorp, College Station, Texas, United States).

Results

Demographics

The sample was relatively representative of the demographic distribution of the PCPs in the primary care network in terms of age, gender, and ethnicity.

Quantitative Results

Baseline survey results ([Table 1]) showed that the PCPs followed different guidelines for PSA screening. Five PCPs followed the 2018 USPSTF grade C recommendation, i.e., individual decision-making for men aged 55 to 69 years, although PCPs felt that current evidence regarding the benefits and harms of PSA screening better supported either a grade A or B recommendation, i.e., “Offer or provide this service.” Most PCPs (7/10) similarly agreed with the USPSTF grade D recommendation against PSA screening in men ≥70 years. Most PCPs (8/10) recommended routine and annual PSA screening for a select group of men, but the age range for which screening was recommended varied. Most agreed that 50 years was an appropriate start age and 70 years was an appropriate stop age, with a few PCPs who recommended continuing PSA screening up to age 75 years. The extent to which PCPs engaged in SDM when discussing PSA screening with their patients varied, with eight PCPs practicing SDM almost always or often and reporting these discussions to be very brief (<5 minutes). Seven PCPs found that engaging in SDM about PSA screening was burdensome, and nine had never previously used a decision aid for PSA screening with patients. While eight PCPs felt somewhat to very confident about their ability to discuss PSA screening with their patients, nine reported yes or maybe when asked if it would be helpful to have a provider-facing EHR-based platform to assist with these discussions and provide guidance; however, six were concerned that it would increase their work burden.

Table 1 Baseline survey (N = 10)

Question	N	(%)
Which guideline regarding prostate-specific antigen (PSA) screening for early detection of prostate cancer do you currently follow in your clinical practice?
United States Preventive Services Task Force (USPSTF)	5	(50%)
American College of Physicians (ACP)	1	(10%)
American Urological Association (AUA)	1	(10%)
Local guideline at practice site	1	(10%)
More than one guideline (ACP, USPSTF)	1	(10%)
No guideline	1	(10%)
American Cancer Society (ACS)	0	(0%)
American Society of Clinical Oncology (ASCO)	0	(0%)
National Comprehensive Cancer Network (NCCN)	0	(0%)
Memorial Sloan Kettering Cancer Center (MSK)	0	(0%)
Do you currently recommend routine PSA screening for a select group of men?
Yes	8	(80%)
No	2	(20%)
For which age groups do you currently recommend PSA screening?
45–74 years	3	(30%)
50–69 years	3	(30%)
50–74 years	3	(30%)
50–79 years	1	(10%)
How often do you suggest men in the relevant age range be screened for prostate cancer?
Every year	5	(50%)
Every 1–2 years	1	(10%)
Every 2 years	1	(10%)
I follow an algorithm based on age and PSA levels	1	(10%)
I do not recommend PSA screening	1	(10%)
Other	1	(10%)
When you discuss PSA screening, to what extent do you engage in shared decision-making?
Almost always	4	(40%)
Often	4	(40%)
Sometimes	1	(10%)
Seldom	1	(10%)
Never	0	(0%)
How long does an average discussion regarding PSA screening take with your patient?
<5 minutes	8	(80%)
<10 minutes	2	(20%)
To what extent do you agree with the following statement: “I find engaging in shared decision-making about PSA screening burdensome.”?
Strongly agree	3	(30%)
Agree	4	(40%)
Don't know	1	(10%)
Disagree	1	(10%)
Strongly disagree	1	(10%)
Have you ever used a decision-aid to help your patients decide about PSA screening?
Yes	1	(10%)
No	9	(90%)
On a scale from 1 to 5, how confident do you feel about your ability to discuss PSA screening with your patients?
1) Not at all confident	0	(0%)
2)	2	(20%)
3) Somewhat confident	3	(30%)
4)	4	(40%)
5) Very confident	1	(10%)
Would it be helpful to you if there was a provider-facing electronic health record (EHR)-based platform to assist with PSA-screening decisions?”
Yes	6	(60%)
No	1	(10%)
Maybe	3	(30%)
How do you think such an EMR-based platform would change your work burden?
It would likely lessen it	2	(20%)
It would probably not affect it	2	(20%)
It would likely add more burden	6	(60%)
How would you want such an EMR-based tool to be?
It should instruct me what to do	2	(20%)
It should provide guidance	7	(70%)
I do not want a tool	1	(10%)
In your own view, which grade recommendation do you feel that the current (as of 2018) evidence on the benefits and harms of PSA screening best supports—for appropriately selected age groups?
Grade A (Recommend)	2	(20%)
Grade B (Recommend)	2	(20%)
Grade C (Shared decision-making)	5	(50%)
Grade D (Do not recommend)	1	(10%)
Grade I (Insufficient evidence)	0	(0%)
To what extent do you agree with the USPSTF grade C recommendation for men ages 55–69 years?
Strongly agree	0	(0%)
Agree	7	(70%)
Neither agree nor disagree	1	(10%)
Disagree	2	(20%)
Strongly disagree	0	(0%)
Do you follow the USPSTF grade C recommendation for men ages 55–69 years?
Yes	7	(70%)
No	2	(20%)
Other	1	(10%)
To what extent do you agree with the USPSTF grade D recommendation for men ages ≥70 years?
Strongly agree	1	(10%)
Agree	5	(50%)
Neither agree nor disagree	2	(20%)
Disagree	2	(20%)
Strongly disagree	0	(0%)
Do you follow the USPSTF grade D recommendation for men ages >70 years?
Yes	4	(40%)
No	4	(40%)
Other	2	(20%)
What age range do you think is appropriate to START PSA screening, for men of average risk?
45 years	1	(10%)
50 years	7	(70%)
55 years	1	(10%)
Missing	1	(10%)
What age range do you think is appropriate to STOP PSA screening, for men of average risk?
65 years	1	(10%)
70 years	5	(50%)
75 years	3	(30%)
Missing	1	(10%)
How many years have you been in practice?	18 years (5–22 years)[a]

Abbreviations: EHR, electronic health record; EMR, electronic medical record; PSA, prostate-specific antigen; USPSTF, U.S. Preventive Services Task Force.

^a Reported as median (IQR).

Qualitative Results

Three major themes arose from the data, with subthemes and illustrative quotes as shown in [Table 2].

Table 2 Themes and subthemes from qualitative analysis of focus group

Themes	Example quotes from PCPs
Theme 1: Confirmatory reactions regarding the importance, innovation, and unmet need for a decision support tool embedded in the EHR
A decision support tool integrated in the EHR was felt to be helpful to the PCPs	“That is the power of computers actually. It's not just books.”
	“Having this guideline, knowing this now, it makes me feel more comfortable with ordering the initial PSA, because sometimes I think one of the reasons why I do shared decision-making is that I'm worried that a man is going to get some elevated PSA and then because of their own anxiety about worrying that they have cancer they're going to go all the way down the path.”
A decision tool to facilitate SDM conversations was found to be useful	“Patients remember about 2% of what I tell them. And then they're like, “Well, my doctor told me something.” But if we have this, this looks good. And if it's something that we could have also in print that a patient could take home with them so that they can think about it in their home and not in the office setting where they have a clear mind, I think that would be great.”
	“Something like this [Simple Schema] would be really nice I think to have layman's terms. One in English, one in Spanish maybe. But so that you can go over this with them. Because I can think about talking to a patient, discussing all these numbers”
	“I do it a lot [hand out patient information].”
	“I'm a big fan of giving information. And I used to literally hand them to folks.”
PCPs preferred to have one tool that could automate and build in the patient's PSA history and other factors	“To me it should be one tool. And then if there's information available on previous PSAs you would want to incorporate it and have the logic incorporate whatever's available that we have some evidence on.”
	“Yeah, prepopulated from previous PSAs.”
	“We can't be manually entering numbers.”
	“And then it's going to incorporate the previous PSA, the age, the race, family history to the extent that can be populated.”
	“But that would be amazing too...because Epic can pull their past PSA and it knows how old they are so it should be able to just highlight something and be like, 'Why didn't you do this before?'”
	“So does that mean that the tool is not only going to recognize de novo screening? But it will also take into account that they have one PSA and start rationalizing when repeat testing will occur? Is it able to do that? That would be useful. I agree with that.”
	“If there were a way to incorporate into the tool whether the patient is on finasteride because that actually does influence how you read their PSA level. That would be helpful.”
	“Can you pull things in and automatically populate if there's a PSA, family history, if there's finasteride on the med list.”
	“Or just list it in a pop-up box. Say PSA is 1. Remember if your patient is on finasteride double it.”
Learning from other decision support tools in the EHR: liked features	“I kind of like the health maintenance tool. I utilize it a lot. And there's ways to do modifiers like for colonoscopies. I think that could be really helpful. If you have a modifier, OK, PSA every two years, PSA every one year. It would be helpful, sure.”
	“The health maintenance thing, I would love to automate that. But as we know from colonoscopies and stuff it defaults to 10 and if you want to change it you got to change it manually.”
	“I would prefer to have it as a health maintenance thing and something that fires at the time of ordering. I think that would be great.”
	“If we were going to try to build something into health maintenance, we could set a due date.”
	“What we could do is at two—for instance in my young patients where it's like the chlamydia screening of influenza, when it's coming like a month before it's due, it's not red, that little clock, it's white, that little clock. If you make that clock white after two years then you know it's like OK. But then after four years it turns red.”
	“Did you ever think of using a thing like with radiology where you hit a button and then it asks you a series of questions, then at the end of it tells you whether the MRI is number six, number two, whatever.”
Learning from other decision support tools in the EHR: disliked features (alert fatigue, burden, clicks, availability)	“People ignore the BPAs, right?”
	“We want to minimize the number of manual inputs that you have to do to arrive at the best decision.”
	“I actually now will try using health maintenance more but I haven't been actually using it. So for those of us who don't utilize health maintenance as much it would be nice. I know it's passive and it's a pain but it's at least something in front of us in the plan section.”
	“But there are people out there that are in solo or private practice that might not have the kind of decision support tools that we have.”
The tool could help document that SDM has taken place	“…we're supposed to do shared decision-making for lung cancer screening, and there is a code for that you can drop and get paid for that counseling. Whether they get the CT or not you still can drop the code.”
	“So if you go ahead and do shared decision-making and you don't order a PSA you don't get any credit for that…and this tool actually is set up in a way that you can get credit for that.”
	“I do think this could give a trigger that would help make sure you drop the code because I know in my practice we have a hard time remembering to use all the depression screening codes even the stuff that we are doing, we're not taking credit for.”
	“Would that be somehow documented? Because it'd be great if those little boxes that you hit, it spits out something that is the documentation.”
Theme 2: Issues around implementation and application of tool in clinic workflow and physicians own clinical bias coloring conversations
Concerns that conversations about PSA screening are challenging and time-consuming	[In response to moderator question: How many minutes do you have on average for your visits?] “Negative five.”
	“I ask about their symptoms … in my mind I let out a big sigh because I know that will take a bit of time.”
Clinicians have their own biases for or against PSA screening and shared decision-making should be kept simple	“I talk about the pros and cons of the test. I talk about the fact that there's limited alternatives. And really that's the quick and easy conversation.”
	“I try to talk about risk and the benefit…I talk about that almost everyone's going to get prostate cancer, very few men will die from it, that being said, some men will, the evidence is controversial, and so talk through here's the path, you could stop at any point on the path, and you're welcome to go forward on the path as long as you understand that some point on the path has some risks associated with it. And usually some men are just like, “Yeah, let's do it.” Then some men are like, “Oh, I would never want a biopsy, I would never want surgery.” Then what's the point of checking? But I do get a lot of the same: “Well, what would you do?” Which is hard because I will never be in that position.”
	“The discussion is colored by our own experiences. And so I try to say a little bit about my own biases because my grandfather had prostate cancer, my father had prostate cancer, they both had really awful side effects from treatment, which they both went through, and they both wished that they hadn't. So that's my own bias. And I try to get rid of that bias. But I don't see how I could not have it. But so I usually just say, 'It's up to you. It's a really hard decision.'”
	“If you do it a couple times you're going to—it's going to be ingrained in your head. It's going to be super quick.”
	“If they're like, 'I don't know, what would you do?' I'd probably order the test.”
	“I think it's just hard…I guess I'm slightly biased against the PSA because I feel like it opens up such a huge can of worms that I need to look for an excuse to get the PSA.”
	“[For rescreening] I don't go through the whole thing again. I just say, “I notice last year you said no. Is that still the case?” Leave it at that. I don't do this again.”
	“Numerical estimates are still really difficult for people to interpret.”
The tool should not be rigid and allow for flexibility and leeway for PCPs to do what they want based on clinical judgment	“I think the challenge that I'm thinking about is how I would factor all this into an aid or whatever you're trying to develop. It's hard for me to follow. I guess what I was hoping that would come out of this is that you should talk to your patient and recommend a PSA, or if it's going to be the opposite, engage with him in conversation. I think it goes back to try to look at the overall picture of the patient.”
	“I'm struggling with the same thing. And I think maybe we can have a tool that's a support tool that could be one size fits all for most. But then there's still the individual judgment, the clinician's judgment that can override or ignore whatever the tool tells. Could that be an option?”
	“I like them [re-screening intervals in guideline]. I think there are still going to be people who want their PSA every year. In which case like you said if they want it it's hard to say—you can discuss numbers with them but sometimes I'm going to end up doing it off of that guideline. Or not in concert with that guideline. Because of patient preference I guess and not wanting to ration them.”
Theme 3: Attitudes/reflections regarding discrepant recommendations from various guideline groups that cause confusion
PSA screening guidelines are discrepant, confusing, and changing	“I read the guidelines from time to time. They're all over the place.”
	“They're all over the map.”
	“I can't remember each one.”
	“They keep changing.”
	“I can't tell you I'd pick one over the other.”
	“The real problem with all these guidelines is that they're all over the map…some societies say screen everybody whereas others looked at all the evidence trying to be as agnostic as possible…it's hard to get into that nuanced discussion with a patient.”
Discrepant views regarding whether or not to combine PSA with DRE	“I never do one, a DRE, for screening. Sometimes I'm doing a PSA and sometimes I don't unless somebody's having some symptom.”
	“If I'm going to do it I do both.”
	“If I'm going to be sending them to urology I feel like I need to do a DRE, I just feel like it's poor form not to have done that.”
	“For wellness [visits] I'm doing a DRE anyway in that age group, rectal exam, not just the prostate exam.”
	“Both.”
	“That should be the primary screening tool—both.”
	“I think no DRE.”
	“No DRE.”
	“Either PSA or PSA plus DRE.”
	“Maybe I'm just a bit more nuanced. I try to look at the information presented to me and for me a lot of it has to do, especially if it's relatively younger gentleman, with symptoms. So if they're having any urological symptoms I'm more likely to do all of the above. Whereas if they're having nothing then I might not…I put a lot of emphasis on what they're telling me.”
Age to start screening	“I would start checking at 50, but if a man wants it checked I check it.”
	“I think the general guidelines say 50.”
	“50 unless there's a strong family history.”
PCPs consider risk factors in SDM conversations and PSA-screening decisions	“Family history of prostate cancer pushes me. Family history leads me down a different path.”
	“If the family member has metastatic prostate cancer at the time of diagnosis that would push me. I don't know if there's any evidence for that, but that would push me to do it. Unless if they're like, “Oh, I think my dad has it, he's 98 years old.”
	“If they're African American, I start earlier. Earlier than 45 too.”
Age to stop screening	“I have a lot of older male patients who really, really want it even though they're over 70 and so I find I so have to spend a lot of time on explaining why we stop at 70 and that's a hard conversation because then it feels to them like I'm stopping something they've always had.”
	“I'm thinking about this one gentleman who was 80 and insisted on it [the PSA-test] for a few visits, over and over again. I finally just checked it. And thank God it was actually under 1 [µg/L] which I was amazed by. Because I was so scared checking it that it was going to be an equivocal number, then what we're going to do with that, and how embarrassing it would be to send to urology. But eventually I gave in to that because it was so—he felt like I was rationing.”
	“It's hard to stop PSA screening. So we see this potentially as a tool to help you do the recommended thing. To say to the patient, “Look, the computer tells me I'm not supposed to.” “Yeah. That would be actually be really helpful.”
The PCPs prefer to refer a man with elevated PSA to urology without any reflex testing done in primary care and challenges with insurance policies	“I'm interested about the reflex testing. It's not only which one is right. Because there are about 20 of these. Every year new ones get put on the market. Other ones drop out. It's very much in flux. Also, the insurance companies don't always pay. So you have to have a conversation with your patient about what's going to happen if they don't pay for it. You have to work with the company in order to figure out how it's going to be. “
	“Don't want to be fighting with the insurance company about whether they get MRI or not. It's a lot of work.”
	“I don't order reflex tests. That's more for the urologist.”

Abbreviations: BPAs, best practice advisories; CT, computed tomography; DRE, digital rectal examination; EHR, electronic health record; MRI, magnetic resonance imaging; PCPs, primary care physicians; PSA, prostate-specific antigen; SDM, shared decision-making.

Theme 1: Confirmatory Reactions Regarding the Importance, Innovation, and Unmet Need for a CDS Tool Embedded in the EHR

PCPs felt that a CDS tool integrated in the EHR would be helpful. PCPs preferred to have one tool that could ideally automate and build in the patient's PSA history and other factors. Important factors noted by the PCPs were: age, family history, symptoms, race, previous PSA tests, medication (e.g., finasteride), and patient preference given the pros and cons of the PSA test. A tool that could automatically pull information from the EHR was a particularly desired feature.

PCPs suggested learning from other CDS tools in the EHR, both good examples and perceived mistakes with other tools. While there was some concern that the tool may take away from face-to-face conversation, PCPs felt that timing and usage of the tool while interacting with a patient was important. There was general acknowledgment that the tool should help, not hurt, current workflows. PCPs appreciated that the tool could give them rationale to aid their clinical judgment, and concrete cut-offs were felt to be helpful. Incorporating a health maintenance module was a particularly desired feature, one that is utilized in other CDS tools currently available in the EHR in clinical practice. One PCP suggested: “For instance in my young patients where it's like the chlamydia screening or influenza, when it's coming like a month before it's due, it's not red, that little clock, it's white, that little clock. If you make that clock white after two years then you know it's like OK. But then after four years it turns red.” However, PCPs also acknowledged challenges with the need to pick a discrete point for the re-screening interval, and there was no consensus about the choice. Some suggested for the clinician to set the interval length, while others suggested to pick the midway of an interval (e.g., 2 years if the interval is 1–3 years) and have a red clock at the end of the interval for repeat screening. Disliked features with prior CDS tools in the EHR were mentioned, including alert fatigue, burden, clicks, and availability. One PCP said, “People ignore the BPA's, right?”

A decision tool to facilitate SDM conversations, which is something that PCPs struggle with, was found to be particularly useful. When shown an example of a decision aid to support SDM conversations about PSA screening (Simple Schema[10]) and asked to comment, PCPs found this useful. One participant said: “Something like this [Simple Schema] would be really nice I think to have layman's terms. One in English, one in Spanish maybe. But so that you can go over this with them. Because I can think about talking to a patient, discussing all these numbers.” Another participant described: “Patients remember about 2% of what I tell them. And then they're like, 'Well, my doctor told me something.' But if we have this, this looks good. And if it's something that we could have also in print that a patient could take home with them so that they can think about it in their home and not in the office setting where they have a clear mind, I think that would be great.”

PCPs preferred for SDM to be kept simple due to time constraints, avoiding one's own biases if possible, tailoring the information to the patient's literacy and numeracy level, writing in layman's language, and if the patient wants the PSA test, ordering it. The Simple Schema was specifically designed for primary care and to not require more than a few minutes.[10] This design can alleviate concerns about PSA screening conversations being time-consuming.

PCPs appreciated that the tool would document that SDM has taken place by showing a code, and gave the example of coding SDM prior to ordering computer tomography scan for lung cancer screening. One PCP asked: “Would that be somehow documented? Because it'd be great if those little boxes that you hit, it spits out something that is the documentation.”

Theme 2: Issues Around Implementation and Application of the Tool in Clinic Workflow and PCPs Own Clinical Bias Coloring Conversations

PCPs expressed concerns that conversations about PSA screening are challenging and time-consuming. One PCP responded: “Negative five” in response to the question: How many minutes do you have on average for your visits? PCPs also explained that clinicians have their own biases for or against PSA screening and SDM should be kept simple. One PCP said: “I think it's just hard…I guess I'm slightly biased against the PSA because I feel like it opens up such a huge can of worms that I need to look for [a good reason] to get the PSA.” Another said: “I talk about the pros and cons of the test. I talk about the fact that there's limited alternatives. And really that's the quick and easy conversation.”

All PCPs agreed that the tool should not be rigid but allow for flexibility and leeway for PCPs to do what they want based on clinical judgment. It should be a guide for helping physician judgment, which should always triumph the computer tool. Therefore, an important feature of the tool was to allow for flexibility and leeway for clinical judgment, given guideline discrepancies and patient factors; PCPs did not want the tool to be too algorithmic.

Theme 3: Attitudes/Reflections Regarding Discrepant Recommendations from Various Guideline Groups That Cause Confusion

PCPs acknowledged that the PSA-screening guidelines are discrepant, confusing, and continually changing, expressing: “They're all over the map”; “I can't remember each one”; and “They keep changing.” Most clinicians agreed with the guideline-recommended ages to start and stop screening but described that, for example, strong family history, African ancestry, or patient preference push clinicians to start screening earlier. The PCPs described: “Family history of prostate cancer pushes me. Family history leads me down a different path”; “If they're African American, I start earlier. Earlier than 45 too”; and “I would start checking at 50, but if a man wants it checked I check it.” PCPs generally accepted the NCCN guideline algorithm and preferred screening to start at 50 years for most, but 45 years if risk factors merited it. The age to stop screening varied among PCPs, sometimes at 70 years, sometimes up to 75 years. Conversations to stop screening were felt to be particularly difficult and having a tool to help give a rationale to stop screening was felt to be beneficial. One PCP said: “I have a lot of older male patients who really, really want it even though they're over 70 and so I find I so have to spend a lot of time on explaining why we stop at 70 and that's a hard conversation because then it feels to them like I'm stopping something they've always had.”

There were discrepant views regarding whether to combine PSA with DRE for screening. Some clinicians also included DRE as a primary screening test in conjunction with the PSA test, whereas others did not. One PCP said: “I never do one, a DRE, for screening. Sometimes I'm doing a PSA and sometimes I don't unless somebody's having some symptom.” While another said: “If I'm going to do it I do both.” PCPs describe a delegation of duties between the PCP and the urologist, and that DRE can be done before sending a referral. One PCP described: “If I'm going to be sending them to urology I feel like I need to do a DRE, I just feel like it's poor form not to have done that.” PCPs further described their preference to refer a man with elevated PSA to urology without any additional testing done in primary care and challenges with insurance policies, as one PCP described: “I don't order reflex tests. That's more for the urologist.”

Discussion

In this study, we developed a CDS tool for PSA screening for prostate cancer in the primary care setting, leveraging the EHR. We gauged PCPs' interest in and attitudes toward PSA screening and CDS tools using both quantitative (survey) and qualitative methods (focus group). Next, we programmed the tool into an EHR system and refined the tool based on feedback from the PCPs.

Our study confirms prior observations. PCPs were using multiple different guidelines, confirming that differing guideline recommendations caused confusion. Although most PCPs felt confident in discussing PSA screening, this contrasted their actual knowledge about the topic. Some wanted to add DRE as a screening test to PSA, while others did not. Evidence suggests that DRE has a poor positive predictive value as a screening tool and its greatest utility is in men with elevated PSA.[24] [25] The majority of PCPs found current approaches to SDM about PSA to be burdensome, and almost no one had used a decision aid, confirming the limited uptake of SDM and decision aids in clinical practice. Feedback regarding the need for a CDS tool to assist with PSA-screening decisions in primary care was overwhelmingly positive, and the majority liked the Simple Schema. The ability to document in the EHR that SDM had taken place was a particularly desirable feature of the tool. The health maintenance feature to automatically reschedule the next PSA test using the tool was also liked by the PCPs.

Similar initiatives have been undertaken. Shelton et al and Presti et al developed CDS for PSA screening in the Veterans Affairs (VA) system and Kaiser Permanente, respectively. Both tools focused on reducing overuse of PSA among elderly men through a pop-up alert in the EHR, reminding PCPs about the nonrecommendation; however, these implementation studies were not preceded by qualitative focus groups with end users.[26] [27] This is not unique to PSA-screening decision aids. In surveying 170 VA primary care clinics regarding clinicians' perceived utility of CDS, there was wide variability in user-centered design practices. While the implementation of most tools was accompanied by pilot testing, provider satisfaction assessment, and impact on performance, only one third were preceded by formal usability assessment.[28] Having physician buy-in of the tool is important to ensure acceptability and use of the tool, as intended, to ensure guideline-concordant care. For instance, PCPs voluntarily chose to use a CDS tool based on cardiology guidelines on statin therapy initiation, and this improved guideline-concordant statin prescription uptake.[29]

Such tools may also have beneficial downstream effects on health outcomes. A systematic review of nine studies regarding electronic CDS tools for diagnosis of cancer in primary care showed improvements not only in the decision-making process but also in the quality of referrals, cost-effectiveness, and earlier diagnosis. The review also acknowledged barriers to implementation, including physician mistrust in the tool, disagreement with the recommendation and guidelines embedded within the tool, and interruption to clinical workflow[30]—similar to the themes found in this focus group study and also confirmed by other studies with providers regarding their views on implementing these tools in primary care, together with the worry of alert fatigue and burden for the end-users.[31] [32]

Shah et al implemented an EHR-based-algorithm for risk-stratified prostate cancer screening in a primary care network of 300 clinicians at 40 sites in North Carolina and compared pre- versus postimplementation outcomes. The algorithm was based on a mix of national guidelines (USPSTF, NCCN, American Cancer Society). The tool comprised a health maintenance module with personalized screening reminders, together with tailored messaging to PCPs about the PSA results. Implementation of the tool increased guideline-concordant care in the postimplementation period.[33]

Limitations of our study include a small and self-selected, nonrandom, convenience sample of PCPs within one primary care network, possibly comprising the least busy PCPs who responded to the study invitation first, limiting generalizability to other primary care settings.

Conclusion

There was overwhelmingly positive support for the need for a provider-facing CDS tool to help with PSA-screening decisions in the primary care setting. Incorporation of suggestions by PCPs from this focus group into a version 2 of the CDS tool will be used in subsequent pilot testing in clinic. Future development of this CDS tool could potentially include harnessing eHealth systems and patient- and imaging-related factors to develop for risk stratification methods. One such platform example was recently reported.[34] The basis of this CDS tool may also be considered for other clinical scenarios outside of PSA, an area for future study.

Clinical Relevance Statement

We conducted a focus group and a survey with 10 primary care PCPs and found positive support for the need for a provider-facing decision support tool to assist with prostate cancer screening decisions in the primary care setting.

Multiple Choice Questions

1. Why can engaging in shared decision-making for prostate-specific antigen screening be challenging to do in clinical practice?

   • Primary care physicians work under time-constraint.

   • Guideline groups differ in their recommendations.

   • It is a complex topic.

   • All of the above.

   Correct Answer: The correct answer is option d. The literature has documented these challenges to shared decision-making for prostate cancer screening.

2. According to this study, primary care physicians may benefit from a provider-facing decision support tool for prostate cancer screening that is embedded in the electronic medical record, because…

   • There is an unmet need.

   • It is important and innovative.

   • It can be integrated in the clinical workflow.

   • All of the above.

   Correct Answer: The correct answer is option d. A focus group confirmed these factors.

Conflict of Interest

None declared.

Acknowledgments

We thank Junaid Nabi, MD, MPH for assistance with coordinating study activities. We thank Kathleen Lynch, MPH, qualitative methods specialist in the Department of Psychology and Behavioral Sciences at Memorial Sloan Kettering Cancer Center for methodological consultation and assistance with the qualitative analysis. We thank Konstantina Matsoukas, Research Informationist at Memorial Sloan Kettering Cancer Center, for kind assistance with the literature review.

Protection of Human and Animal Subjects

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was approved by the institutional review board at both BWH and MSK.

Note

S.V.C. has received travel reimbursement and speaker honorarium from Ipsen and has served on an advisory board for Prostatype Genomics, unrelated to this study.

Disclaimer

The funding agencies had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit it for publication. The content is solely the responsibility of the authors.

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Publikationsverlauf

Eingereicht: 12. September 2023

Angenommen: 12. Februar 2024

Artikel online veröffentlicht:
10. April 2024