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MammoScreen: Using Interoperable Standards Within a Clinical Decision Support Tool to Increase Appropriate Breast Cancer Screening and Prevention

MammoScreen: Using Interoperable Standards Within a Clinical Decision Support Tool to Increase Appropriate Breast Cancer Screening and Prevention

Integrating patient-generated breast cancer risk information with patients’ electronic health records will enhance decision support for clinicians and patients and improve screening and preventive services for patients.

Data to support decision making: available but not accessible

The U.S. Preventive Services Task Force (USPSTF) recommends three breast cancer screening and preventive services based on evidence of benefits and harms: 1) periodic mammography screening, 2) risk assessment and testing for the BRCA1/2 gene mutations that increase risk for breast cancer, and 3) use of risk-reducing medications for women at increased risk. However, women may not receive these recommended services because risk information may be unavailable, inaccurate or incomplete, or difficult to access in most electronic health record (EHR) systems.

To address this issue, an Oregon Health and Science University-based team, led by Drs. Karen Eden and Heidi Nelson, developed MammoScreen, a web-based application of a clinical decision support tool. Designed for women from 40–74 years old, this tool is used to identify an individual’s risk for breast cancer, and then engage the patient in shared decision making with their clinician to guide referrals and consider different screening and prevention decisions. While MammoScreen was well received by both patients and clinicians and provided comprehensive and accurate information, its use hinged on manual data entry into the EHR; this would not be sustainable across large patient populations or health systems.

The technology challenge in using the decision aid in clinical practice arose because the information that resides in MammoScreen and in the EHR doesn’t magically flow between them. This research funding supports getting these two systems to work together, so that the clinician gets integrated information about breast cancer risk from the patient via MammoScreen.”
– Dr. Eden

Cue SMART on FHIR®

To address this issue, Drs. Eden and Nelson approached Dr. William Hersh, a leader in healthcare informatics, to help identify a solution for integration. Dr. Hersh proposed that MammoScreen would be a great application for use with Substitutable Medical Applications, Reusable Technologies (SMART) on Fast Healthcare Interoperability Resources (FHIR®) standards to exchange data. Using SMART on FHIR will allow MammoScreen to integrate directly with the EHR, to provide patient-personalized decision support for both patients and clinicians and, in turn, improve quality of care for appropriate breast cancer screening and prevention.

While SMART on FHIR is new and innovative in healthcare, the idea of moving data back and forth between applications and then displaying them in apps has been around for a decade. We do it on our phones every day. However, this is more challenging in medicine. The data are more complex, the data are more personal. We need to protect them better. SMART on FHIR provides a solution to the problem of supporting communicating between the electronic health record and apps like MammoScreen.”
– Dr. Hersh

Two-way communication between MammoScreen and the EHR will support decision making

With the SMART on FHIR integration, patient data from the EHR will be pulled into the tool, so that women will not have to enter existing data. Women will be able to identify and update any incorrect and outdated information, and corrections will be tracked. The resulting risk category (above average or average risk) and breast symptoms identified with MammoScreen will then be stored in the EHR for clinicians to review to guide appropriate care. Once the integration is complete, the team will evaluate its use among patients and clinicians using mixed methods based on the RE-AIM framework. The team expects that the use of this implementation framework will enhance decision support for clinicians and patients and improve screening and preventive services for patients.