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Experience and Potential for Transformational Change in Cancer Care Delivery

Experience and Potential for Transformational Change in Cancer Care Delivery

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Haggstrom Regenstrief Conf2 Haggstrom Regenstrief Conf2 Presentation Transcript

  • Experience and Potential for Transformational Change in Cancer Care Delivery David A. Haggstrom, MD, MAS Regenstrief Conference October 3, 2007
  • Tranformational change
    • “ Together we can transform the American health care system into one that provides the highest quality of care for all of its citizens. ”
      • Carolyn Clancy, AHRQ
    • Connect the System. Through electronic health records, standards, and information exchange.
    • Measure and Publish Quality. Work with doctors and hospitals to define benchmarks for what constitutes quality care.
    • Measure and Publish Price. Agreement is needed on what procedures are covered in each "episode of care."
    • Create Positive Incentives.   Reward those who offer & those who purchase high-quality, competitively priced health care.
  • RAND quality report
    • Individuals receive 55% of recommended care
    • “ A key component of any solution…is the routine availability of information on performance at all levels . Making such information available will require a major overhaul of our current health information systems , with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality.”
    McGlynn E et al., NEJM, 2003.
  • Cancer policy statements
    • Institute of Medicine , April 1999:
    • “ A cancer data system is needed that can provide quality benchmarks for use by systems of care: hospitals, provider groups, and managed care systems ”
    • National Cancer Institute, cancer.gov , 2002:
    • “ Work is underway to make cancer a working model for quality of care research and the translation of this research into practice ”
    • Regenstrief Cancer Care Engineering , May 2007:
    • “ Develop an hierarchical system-based approach to improving cancer care: establishing an Indiana prototype for colorectal cancer care ”
  • National Initiative for Cancer Care Quality
      • Development of quality measures :
        • Literature review of existing indicators, guidelines, RCTs
        • Subsequent expert review (clinical, health services researchers, nurses, patients)
      • Method : patient survey & medical record review
        • 47% of eligible patients enrolled
      • Proportion of patients who received recommended care
        • 86% of breast cancer patients
          • Adherence less than 85% for 18/36 breast cancer measures
        • 78% of colorectal cancer patients
          • Adherence less than 85% for 14/25 colorectal ca measures
      • Colorectal cancer post-treatment surveillance: 50%
      • Appropriate referral: 13-59%
      • Respect for patient preferences: 57-71%
    Schneider E et al., Jnl Clin Onc, 2005.
  • Outline
    • How do we measure quality?
    • With what data do we measure quality?
    • What technologies can transform our use of quality data?
      • health information exchange
      • clinical decision support
      • personal health records
    • How do we study technology implementation?
    • Who is accountable for quality?
      • provider-level
      • system-level
      • patient-level
    Data Quality measure Transformative technology Provider Patient System
  • Health care quality and Overutilization
    • Application of medical interventions without known medical benefit, or worse , with known lack of benefit
    • Overtreated: Why too much medicine is making us sicker and poorer , Shannon Brownlee, 2007
    • Cancer examples :
      • bone marrow transplant for breast cancer
      • PSA screening
      • surveillance testing
    Unmeasured quality gap Good Quality Poor Quality Good Quality Underuse Overuse
    • Clinical uncertainty
      • Risk adjustment
    • Decision-making uncertainty
      • Patient preferences & values vary
      • Measure “informed” or “good decisions” in concordance with patient preferences, Mulley et al.
    Unmeasured quality gap Good Quality Poor Quality Health care quality and Uncertainty Uncertainty Certainty
  • Other dimensions of quality
    • Patient satisfaction
    • Patient-provider communication
    • Quality-of-life
    • Symptom control
  • Importance of measurement PDSA cycles Act Plan Study Do Act Plan Study Do
  • How do we measure cancer care quality? Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care General population Cancer population Longitudinal care Recurrence Surveillance
  • With what data do we measure quality? United States
    • Haggstrom DA et al., Cancer . 2005.
    General population SEER cancer registries Medicare Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
  • With what data do we measure quality? Michigan
    • Bradley CJ et al., Cancer , 2005.
    General population Medicare/Medicaid State cancer registry Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
  • With what data do we measure quality? Iowa
    • Doebbeling BN et al., Med Care, 1999.
    General population Private claims State cancer registry Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
  • With what data do we measure quality? Indiana ‘Connect the System’ Cancer population Longitudinal care IN State cancer registry SPIN VA cancer registry
    • VA-INPC
    • longitudinal care
    • Medicare
    • Medicaid
    • Private claims
    • Regenstrief EMR
    • VA admin. claims
    • VA EMR
    • New possibilities
    • with EMR
    • Test results
      • Laboratory
      • Radiology
        • Free text query
    • Add new quality measures in EMR
    • Satisfaction
    • Communication
    • Quality-of-life
    • Symptoms
    LINK
    • Proportion of patients who underwent screening – primary care
    • Adequate lymph node retrieval & evaluation - surgery
    • Proportion receiving radiation therapy/chemotherapy - oncology
    • Proportion who underwent follow-up of abnormal test – who?
    • Proportion receiving postoperative surveillance – who is responsible?
    Primary care – quality measure VA-INPC Cancer population Longitudinal data Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
    • Proportion of patients who underwent screening – primary care
    • Adequate lymph node retrieval & evaluation - surgery
    • Proportion receiving radiation therapy/chemotherapy - oncology
    • Proportion who underwent follow-up of abnormal test – who?
    • Proportion receiving postoperative surveillance – who is responsible?
    Surgery treatment – quality measure Cancer population Longitudinal data VA/INPC Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
    • Proportion of patients who underwent screening – primary care
    • Adequate lymph node retrieval & evaluation - surgery
    • Receipt of radiation therapy/chemotherapy - oncology
    • Proportion who underwent follow-up of abnormal test – who?
    • Proportion receiving postoperative surveillance – who is responsible?
    Oncology treatment – quality measure Cancer population Longitudinal data VA/INPC Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
  • Transformative technology #1: Health information exchange
    • Primary care
    Surgery Oncology timely quality performance reports Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
  • Transformative technology #2: Clinical decision support Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Ave risk / Follow-up of abnormal tests Surveillance colonoscopy ONCWATCH REMINDERS real-time quality performance Cancer screening
    • Control
    • hospitals
    Implementation research of health information technology β site No CDS Active system re-design 5 more hospitals Passive dissemination 5 regional hospitals Learning system
    • 1. CLINICAL PROCESSES
    • Cancer screening
    • Diagnostic colonoscopy
    • Surveillance colonoscopy
    • 2. Organizational surveys
    • Culture
    • Teamwork
    • Leadership
    New CDS Implementation Plan
    • Qualitative data
      • Workflow
      • Usability
    Control hospitals
  • Transformative technology #2: Clinical decision support Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Low risk / Follow-up of abnormal tests Surveillance colonoscopy Physician specialty General internist +/- gastroenterologist +/- surgeon real-time quality performance Cancer screening REMINDERS
    • Proportion who underwent follow-up of abnormal test
    Uncertain accountability Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Primary care Radiologist Proceduralist Who is responsible? Information exchange
    • Proportion receiving postoperative surveillance
    Uncertain accountability Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Primary care Surgery Oncology Who is responsible? Information exchange
  • Approaches to uncertain accountability Promoting continuity in fragmented health care system
    • System approach:
      • Assign provider accountability to larger organizations/units than single provider
    • Patient-centered approach
      • Share accountability through personal health records
  • ‘ Extended medical staff’ definition
    • Data source : Assigned physicians & patients using Medicare claims (2002-2004)
    • Physicians  extended medical staff
      • Inpatient MDs : assign MD to hospital where they provided care to most inpatients
      • Outpatient MDs : assigned MD to hospital where admitted most patients
    • Patients  extended medical staff
      • Inpatients : assigned based on plurality of discharges over specific period
      • Outpatients : assigned to physician (primary or specialty care) who provided most of their care in outpatient setting
        • then assigned to physicians’ primary hospital
    Fisher E et al., Health Affairs, 2006
  • Concentration of patients among extended medical staff 73% % of patient received services from extended medical staff 90% % of physician inpatient work at primary hospital 98% 2% >500 2% 48% 50-499 <1% 50% 0-49 Extended medical staff Individual providers Patient panel size
  • Advantages of ‘extended medical staff’ as locus of accountability ‘Positive incentives’
    • Performance measurement
      • focus on longitudinal experience of patient & address fragmentation of care by pooling accountability
    • Local organizational accountability
      • influence resource distribution, IF measured on BOTH quality & cost
      • larger organizations have capacity to invest in improving quality & lowering costs
  • Patient-centered approach Promoting continuity in fragmented cancer care system
    • Survivorship Care Plan
      • Cancer type, treatment received, & potential toxicities
      • Tailored information about timing & content of recommended follow-up
      • Recommendations regarding preventive practices & how to maintain health & well-being
      • Availability of psychosocial services in community
    • Personal health record
      • Diagnosis, treatment received, & potential side-effects
      • Tailored information about timing & content of recommended follow-up
      • Recommendations regarding preventive practices & how to maintain health & well-being
      • Availability of psychosocial services in community
  • Transformative technology #3: Personal health records Risk Assessment Screening Diagnosis Treatment Surveillance Provider -Oncologist -Radiation therapist -Surgeon -Primary Care -Radiologist -Proceduralist -Primary Care -Primary Care -Oncologist -Surgeon -Radiologist -Proceduralist PHR Palliative care Patient/ caregiver Longitudinal care
    • Current functions :
      • Patient education
      • Self-management tools
      • Pharmacy refills
    • Functions in near future :
      • on-line appointments
      • patient/provider messaging
    • Pilot program :
      • full access to VA electronic health record
  • Study/project designs Appropriate care Clinical processes Quality personal health record no personal health record
  • Patient perceptions quality of cancer care
    • Population : population-based survey of 1,067 patients with colorectal cancer nine months after diagnosis
    • Mean problem score (in descending order):
      • Health information 48
      • Treatment information 32
      • Psychosocial care 32
      • Coordination of care 21
      • Access to care 12
    Ayanian J et al., Jnl Clin Onc, 2005.
  • Racial/ethnic differences patient perceptions of quality of care
  • Health care quality and Access
    • “ Chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”,
    • New York Times ,
    • September 23, 2007
    Unmeasured quality gap Good Quality Poor Quality Population with access to health care system No access
  • Transformation technology & implementation
    • Transformative technologies
      • Information exchange
        •  timely performance feedback
      • Clinical decision support
        •  real-time peformance feedback
      • Personal health records
        •  patient-centered decision support
    • Implementation science
      • Better understand adoption of technology with multiple methods & designs
  • Transformation accountability
      • Solitary episodes of care delivery
        •  accountability for multiple episodes of care shared among multiple providers
          • Large organizations have capacity to act
        •  give health information and recommendations to patient in personal health record
          • Patient is willing to act – patient health is at stake
  • Transformation what we measure is what we change (at least on purpose)
    • Leverage ‘system connectedness’
    • Measure quality in many dimensions
      • Underuse
      • Overuse
      • Access
      • Patient experience
  • Act Plan Study Do Act Plan Study Do
  • Indy quality performance measure the right things at the right time Act Plan Study Do Act Plan Study Do
    • Thank you
  • Health care quality and Overutilization
    • Application of medical interventions without known medical benefit, or worse , with known lack of benefit
    • “ Avoiding the unintended consequences of growth in medical care: how might more be worse?” 1999, JAMA, Fisher E, Welch G
    • Overtreated: Why too much medicine is making us sicker and poorer , Shannon Brownlee, 2007
    • Cancer examples :
      • bone marrow transplant for breast cancer
      • PSA screening
      • surveillance testing
    Unmeasured quality gap Good Quality Poor Quality Good Quality Underuse Overuse
  • Health care quality and Access
    • African Americans more frequently than whites
      • lost medical insurance coverage after cancer diagnosis
      • denied coverage after changing jobs
      • reached their insurance spending limits
    • “ CMS - chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”,
    • New York Times ,
    • September 23, 2007
    Unmeasured quality gap Good Quality Poor Quality Population with access to health care system No access
  • Implementation research
    • Measuring context…
    • Organizational surveys:
      • Teamwork
      • Leadership
      • Culture
    • Qualitative methods
    • Human factors engineering
  • What is measured targets what is changed
    • Approporiate clinical use
    • Overuse
    • Risk-adjusted use
    • Preference-concordant use
    • Patient experience
    • Patient symptoms
    • Access
    • Proportion of care delivered outside the VA for CRC care? Denise Hynes?
  • Importance of measurement PDSA cycles X X Act Plan Study Do Act Plan Study Do
  • Subspecialty care Primary care Unmeasured quality gap Poor Quality Good Quality Shared care
  • Transformative technology #2: Clinical decision support Oncwatch Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Low risk / Follow-up of abnormal tests Surveillance colonoscopy REMINDERS Physician specialty General internist +/- gastroenterologist +/- surgeon real-time feedback Cancer screening
  • Sample sizes 98% 2% >500 2% 48% 50-499 <1% 50% 0-49 Assessment of providers as group (extended medical staff) Assessment of providers as individuals Patient population size
  • Cancer examples of use of non-evidence-based interventions
    • Bone marrow transplant for breast cancer
    • PSA
    • Surveillance tests among cancer survivors
  • Atlanta measures
    • More detail about measures???
    • Control
    • sites
    α / β site Non-OncWatch Active implementation 5 more sites Passive diffusion 5 regional sites Learning system
    • 1. CLINICAL PROCESSES
    • Cancer screening
    • Diagnostic colonoscopy
    • Surveillance colonoscopy
    • 2. Organizational surveys
    • Culture
    • Teamwork
    • Leadership
    OncWatch Implementation Plan
    • Qualitative data
      • Workflow
      • Usability
    Control sites
    • If a man will begin with certainties, he will end in doubts; but if he will be content to begin with doubts, he will end in certainties. -Francis Bacon (1561-1626),_
  • Cancer quality/performance measures
    • Measuring the Quality of Breast Cancer Care in Women
      • Evidence Report/Technology Assessment No. 105. (University of Ottawa Evidence-based Practice Center) AHRQ. October 2004.
    • Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal Cancer
      • (Duke Evidence-based Practice Center) AHRQ. May 2006.
    • Process measures
    • Outcome measures
  • Survivorship care plan
    • Survivorship care plan
    Personal health record
  • Types of uncertainty
    • ERROR : Measure quality of physician performance only by measuring clinical processes.
    • UNINTENDED CONSEQUENCE : Patients making informed and shared decisions with their physicians not to undergo screening or treatment are labeled as receiving poor quality care. Sick patients who would not benefit from aggressive screening or treatment may also be labeled as receiving poor quality care.
    • RESEARCH NEED : In areas of clinical uncertainty, measure quality by measuring the presence of “good decisions”, not only what decision is made. Take into account patient illness or preferences when measuring quality, otherwise, the measures may create incentives for inappropriate or unwanted clinical care.
    • “ The only man who behaves sensibly is my tailor; he takes my measurements anew every time he sees me, while all the rest go on with their old measurements and expect me to fit them”
      • George Bernard Shaw
  • How do we measure performance? Michigan
    • Bradley CJ, Gardiner J, Given CW, Roberts C. Cancer, Medicaid enrollment, and survival disparities. Cancer . 2005 Apr 15;103(8):1712-8.
    • Bradley CJ, Principal Investigator, “In-Depth Examination of Disparities in Cancer Outcomes.”  $1,630,646.  Funding Source:  National Cancer Institute.  2004-2008.
    General population Medicaid State cancer registry Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance
  • Health care quality improvement or implementation research Poor Quality Health Care Good Quality Poor Quality Good Quality
  • Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor
    • Patients
    • Referring Clinicians
    • Purchasers
    INCENTIVE TO CHANGE Pathway 2: SELECTION REPORTS PUBLIC Berwick D, Institute for Healthcare Improvement, Medical Care
  • Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor
    • Patients
    • Referring Clinicians
    • Purchasers
    INCENTIVE TO CHANGE Pathway 2: SELECTION REPORTS PUBLIC Berwick D, Institute for Healthcare Improvement, Medical Care
  • Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor
  • Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor
    • Patients
    • Referring Clinicians
    • Purchasers
    INCENTIVE TO CHANGE Pathway 2: SELECTION REPORTS PUBLIC Berwick D, Institute for Healthcare Improvement, Medical Care
  • Uncertain accountability
    • Cheesy?
  • Diagnosis Cancer Treatment Screening Recurrence Surveillance
    • When Mrs. Hewitt sued Habana over her mother’s death, for example, she found that its owners and managers had spread control of Habana among 15 companies and five layers of firms.
    • As a result, Mrs. Hewitt’s lawyer, like many others confronting privately owned homes, has been unable to establish definitively who was responsible for her mother’s care.
    • New York Times, September 23, 2007
    • The limits of health services research:
      • Public health
      • Chemotherapy for immigrants not covered
  • IOM: Crossing the Quality Chasm
    • Effective
    • Patient-centered
    • Timely
    • Efficient
    • Equitable
    • Safe
  • Tranformational change
    • “ Together we can transform the American health care system into one that provides the highest quality of care for all of its citizens. ”
      • Carolyn Clancy, AHRQ
    • Connect the System. Every medical provider will have some system for electronic health records.  Standards need to be set so all health information systems can quickly and securely communicate and exchange data.
    • Measure and Publish Quality. Every case, every procedure has an outcome.  Some are better than others.  To measure quality, we must work with doctors and hospitals to define benchmarks for what constitutes quality care.
    • Measure and Publish Price. Price information is useless unless cost is calculated for identical services.  Agreement is needed on what procedures are covered in each &quot;episode of care.&quot;
    • Create Positive Incentives.   All parties—providers, patients, insurance plans, and payers—must be subject to contractual arrangements that reward those who offer and those who purchase high-quality, competitively priced health care.
    • “ Changing what is possible”
  • Medicare Medicaid Private Insurance Uninsured Indiana Network for Patient Care Regenstrief Medical Record System (RMRS) General population Cancer population VA INPC State Registry SPIN Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance
  • Risk Assessment Timely Diagnosis Cancer Treatment Screening Surveillance for Recurrence Genomics Risk of Cancer Death
  • Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E
    • Primary care practice
    • VA
    • IU-MG
    VA Medicare Medicaid private insurance Uninsured
  • Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E VA Medicare Medicaid private insurance Uninsured
  • Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E SPIN
  • Transformative technology #3: Personal health records Risk Assessment Screening Diagnosis Treatment Surveillance Patient/ caregiver Provider Provider Provider Provider Provider Follow-up of abnormal tests may be improved by coordination Survivorship care may be improved by coordination Patient/ caregiver Patient/ caregiver PHR Patient/ caregiver Palliative care Patient/ caregiver Longitudinal care
  • VA
  • Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) R E S E A R C H Q U E S T I O N Genomic risk Health Services Research SEER (20% US) State Registries (Indiana) VA Cancer registries
  • Fragmented health care delivery = fragmented data
    • age
    insurance coverage location 65 VA Medicare Medicaid private insurance Uninsured SEER SEER-Medicare Medicare Wellpoint UnitedHealth Medicaid medical record VA INPC
  • Fragmented health care delivery = fragmented data
    • age
    insurance coverage location 65 VA Medicare Medicaid private insurance Uninsured SEER SEER-Medicare
  • Fragmented health care delivery = fragmented data
    • age
    insurance coverage location 65 SEER SEER-Medicare VA Medicare Medicaid private insurance Uninsured
  • Coordination of care across the continuum Risk Assessment Screening Diagnosis Treatment Surveillance Patient Provider Provider Provider Provider Provider Follow-up of abnormal FOBTs may be improved by coordination Survivorship care may be improved by coordination Patient Patient/ caregiver Patient PHR
    • 65
    insurance coverage location
  •  
  •  
  • Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) R E S E A R C H Q U E S T I O N Genomic risk Health Services Research SEER (20% US) State Registries (Indiana) VA Cancer registries
  • Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E
  • Unmeasured quality gap Health Care Good Quality Poor Quality Certainty Clinical uncertainty Health Care Quality and Uncertainty
  • How do we measure performance? Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population SEER Medicare Longitudinal care State cancer registry Medicaid
    • Proportion of patients who underwent screening – primary care
    • Adequate lymph node retrieval & evaluation - surgery
    • Proportion receiving radiation therapy/chemotherapy - oncology
    • Proportion who underwent follow-up of abnormal test – who?
    • Proportion receiving postoperative surveillance – who is responsible?
    Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population State cancer registry Private claims
    • Proportion of patients who underwent screening – primary care
    • Adequate lymph node retrieval & evaluation - surgery
    • Proportion receiving radiation therapy/chemotherapy - oncology
    • Proportion who underwent follow-up of abnormal test – who?
    • Proportion receiving postoperative surveillance – who is responsible?
    Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population Longitudinal data
  • How do we measure performance? Virginia?
    • Penberthy L, McClish D, Manning C, Retchin S, Smith T. The added value of claims for cancer surveillance: results of varying case definitions. Med Care . 2005 Jul;43(7):705-12.
    Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Medicare State cancer registry
    • Proportion of patients who underwent screening – primary care
    • Adequate lymph node retrieval & evaluation - surgery
    • Proportion receiving radiation therapy/chemotherapy - oncology
    • Proportion who underwent follow-up of abnormal test – who?
    • Proportion receiving postoperative surveillance – who is responsible?
    Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population Longitudinal data
  • Coordination of care across the continuum Risk Assessment Screening Diagnosis Treatment Surveillance Patient/ caregiver Provider Provider Provider Provider Provider Follow-up of abnormal FOBTs may be improved by coordination Survivorship care may be improved by coordination Patient/ caregiver Patient/ caregiver Patient/ caregiver PHR