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Improving colon cancer screening rates in 

primary care: a pilot study emphasising the role 

of the medical assistant 

A N Baker, M Parsons, S M Donnelly, et al. 

Qual Saf Health Care 2009 18: 355-359 

doi: 10.1136/qshc.2008.027649 

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http://qshc.bmj.com/content/18/5/355.full.html 

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Original research 

Improving colon cancer screening rates in primary 

care: a pilot study emphasising the role of the 

medical assistant 

A N Baker, 1 M Parsons, 2 S M Donnelly, 1 L Johnson, 1 J Day, 2 A Mervis, 2 B James, 3 

R Burt, 4 M K Magill 2 

1 HealthInsight, Salt Lake City, 

Utah, USA; 2 University of Utah, 

Community Clinics, Salt Lake 

City, Utah, USA; 3 Intermountain 

Health Care, Salt Lake City, 

Utah, USA; 4 University of Utah, 

Huntsman Cancer Institute, Salt 

Lake City, Utah, USA 

Correspondence to: 

Dr M K Magill, Department of 

Family and Preventive Medicine, 

School of Medicine, University of 

Utah, 375 Chipeta Way, Suite A, 

Salt Lake City, UT 84108, USA; 

michael.magill@hsc.utah.edu 

Accepted 7 July 2008 

ABSTRACT 

Background: Colorectal cancer (CRC) is the third-leading 

cause of cancer death for both men and women in the 

USA. Despite consensus recommendations for screening, 

just over half of eligible adults nationally have undergone 

screening. We therefore implemented a programme to 

improve the rate of CRC screening. 

Methods: This study was conducted in the Utah Health 

Research Network and the University of Utah Community 

Clinics, a 100 000 patient, seven-practice, universityowned 

system offering primary and secondary care and 

ancillary services including endoscopy. We focused on 

patients aged >50 who were seen between 1 January 

2003 and 31 October 2006, and who were not current for 

CRC screening at the time of the visit. The study included 

a three-phase intervention: electronic medical record 

(EMR) reminders, physician and medical assistant (MA) 

education about CRC screening guidelines, and redesign 

of patient visit workflow with an expanded role for MAs to 

review patients’ CRC screening status and recommend 

testing when appropriate. With patient agreement, the 

MA entered a preliminary order in the EMR, and the 

physician confirmed or rejected the order. The primary 

outcome measure was the rate of screening colonoscopy 

ordered for eligible patients. 

Results: The baseline colonoscopy referral rate was 

6.0%. Provider education and electronic reminders had 

minimal immediate impact on screening rates. Addition of 

the expanded MA role was associated with a sustained 

increase in colonoscopy referral order rate to 13.4%, a 

relative improvement of 123%. 

Conclusions: The MA can play a key role in improving 

CRC screening rates as part of a redesigned system of 

primary care. 

Colorectal carcinoma (CRC), cancers of the colon 

and rectum combined, are the third most common 

cause of new cancer cases and deaths in the USA 

for both men and women. 1 An individual’s lifetime 

risk of developing CRC in the USA is nearly 6%, 

with over 90% of cases occurring after age 50. 2 

Screening 

Screening can decrease CRC mortality by enabling 

detection and removal of precancerous polyps and 

early cancers before they undergo malignant 

transformation or metastasise. 3 If screening were 

universally applied, up to 90% of all CRC cases and 

deaths would be preventable. 4 5 Consensus evidence-based 

recommendations call for screening of 

all persons beginning at age 50. High-risk individuals 

should begin screening at younger ages and/ 

or more frequently than others. 2 Screening options 

include the use of faecal occult blood testing, 

flexible sigmoidoscopy, contrast barium enema and 

colonoscopy, alone or in combination. Although 

the ideal screening test and protocol are yet to be 

determined, the US Preventive Services Task Force 

ranks colonoscopy as ‘‘the most sensitive and 

specific test for detecting cancer and large polyps.’’ 3 

The use of CRC screening tests in the USA is 

unacceptably low. 6 7 In 2004, 57.3% of adults aged 

>50 years reported having been screened appropriately 

with either faecal occult blood testing or 

colonoscopy. 8 

Strategies to improve screening 

Multiple strategies are used in primary care to 

improve CRC screening rates including patient 

counselling or education, provider education, medical 

record-based protocols and combinations of 

these. 9 10 The advent of the electronic medical 

record (EMR) offers opportunities to provide 

patient-specific reminders and decision support to 

improve screening rates, often combining EMR 

functions with medical practice system changes. 10–18 

Increasingly, investigators are recognising that 

primary care practice improvement requires 

changes in physician and staff roles as part of 

effective teams, with medical assistants (MAs) 

serving a key role. 19 

Education 

Physician education is commonly used in an effort 

to increase CRC screening. However, didactic 

education alone is relatively ineffective at changing 

physician behaviour. 20 Low rates of ordering and 

completion of screening tests for eligible patients 

are likely related to multiple factors including: 

competing priorities during acute-care visits, management 

of chronic illnesses and comorbidities. 10 

CRC screening in particular may encounter added 

patient resistance due to discomfort, cost and 

perceived screening risks, although rates of patient 

refusal of recommended tests such as colonoscopy 

are not well known. 

Reminders 

Implementation of EMR-based reminders or 

prompts has been shown to improve CRC screening 

rates, although provider compliance with 

11–15 17 

prompts is variable. For example, an early 

(1996) study found that more than half of 

electronic reminders did not lead to recommended 

Qual Saf Health Care 2009;18:355–359. doi:10.1136/qshc.2008.027649 355



testing. 14 Reasons for non-compliance with electronic reminders 

include: lack of coordination between nursing staff and 

physicians, physician review of the prompt when the patient 

is absent, competing workload demands and lack of flexibility in 

implementation of the EMR prompt. 15 

Teams: the MA role 

Primary care is complex. Full implementation of all recommended 

evidence-based preventive care, acute care and chronic 

disease management to an average panel of primary care 

patients would require in excess of 18 h per day for a physician 

working in a traditional physician-centred practice model. 21 

Recognition of this reality and of the need to improve quality 

in primary care has led to the emergence of multiple models of 

team-based primary care, virtually all of which include 

significantly enhanced roles for non-physician team members, 

especially MAs. 19 

According to the Bureau of Labor Statistics, the medical 

assistant occupation is projected to be one of the fastestgrowing 

occupations in the 2004–2014 period. 22 Some MAs are 

trained on the job. Many complete 1- to 2-year programmes in 

high schools, postsecondary vocational schools, and community 

and junior colleges. 22 MAs usually work under their supervising 

physician’s license and are ‘‘not licensed to make independent 

medical assessments or give advice.’’ 23 An MA’s greatest value 

may be to help providers optimise office workflow, allowing 

providers to see more patients and accomplish more during 

encounters. 23 In their guide to delivering clinical preventive 

services, the Agency for Healthcare Research and Quality 

emphasises the need to involve all levels of staff in preventive 

services and spread out tasks among staff. 24 However, many 

physicians underassign tasks and do not allow MAs to work to 

their fullest potential. 23 In addition, although many medical 

practices are implementing enhanced MA roles, research 

demonstrating improved quality of care specifically linked to 

these enhanced roles is limited. 

We therefore report here results of a study designed to 

increase CRC screening rates. The three-phase study intervention 

included physician and MA education about CRC screening, 

advanced EMR reminder features and redesigned clinical 

team roles. This last phase of the intervention included 

expanded MA responsibility to review patients’ CRC screening 

status, initiate discussion of recommended tests and prepare 

preliminary orders for patients agreeing to colonoscopy. 

METHODS 

Setting 

This study was conducted in the University of Utah 

Community Clinics (UUCCs) and its research arm, the Utah 

Health Research Network (a practice-based research network 

(PBRN)). At the time of this study, the UUCCs were a 100 000- 

patient, seven-practice, multispecialty, primary care network 

with sites in and around the Salt Lake valley and linked by an 

electronic medical record, EpicCareß (Epic). 

Intervention 

Phase I: EMR prompt for CRC screening 

The UUCCs began using Epic on 1 July 2001. On 15 March 

2002, a computerised reminder suggesting colonoscopy—for all 

patients 50 years or older without previously documented 

colonoscopies—was added to the system. Prior to initiating 

the EMR prompt for the present study, we developed a detailed 

flow chart to describe how this reminder was used in practice to 

identify and refer patients due for CRC screening. Direct 

observations of 30 clinical visits for patients 50 years or older in 

three of the UUCCs revealed that physicians were systematically 

bypassing and ignoring the EMR reminder. The prompt 

appeared at an inopportune time early in the doctor–patient 

encounter, when patients and physicians were focused on the 

patient’s reason for the visit, and did not readily lead to action 

by the clinician. As the first intervention for the present study, a 

refined prompt was implemented in October 2004. 

Phase II: physician and MA education 

Beginning in December 2004, we conducted physician education 

sessions for all UUCC primary care physicians who cared for 

adults (family medicine, internal medicine and obstetrics/ 

gynecology). We also identified physician and MA opinion 

leaders. These leaders attended additional education sessions, 

contributed to clinic workflow redesign and served as liaisons 

for our study, providing feedback to peers and encouraging 

them to make CRC screening a priority. 

Phase III: redesigned clinical workflow 

Beginning in February 2005, we worked with physician opinion 

leaders to alter clinical workflow, assigning MAs the responsibility 

to initiate discussion of CRC screening with the patient 

before being seen by the physician, as the MA was completing 

preliminary patient evaluation. This change took advantage of 

the fact the EMR prompt appeared early in the encounter 

sequence, and separated this discussion from the physician’s 

assessment of the primary reason(s) for the visit. We provided a 

script—written by one of the clinic doctors who was also a 

member of our research team—for MAs to use when the 

electronic prompt indicated the patient was due for CRC 

screening (see table 1). If the patient requested colonoscopy, the 

MA placed a preliminary order for scheduling the test in the 

medical record. This served as a convenient prompt to 

physician–patient discussion of screening at an appropriate 

point in the visit, after assessment of the patient’s reason(s) for 

the visit. Physicians then chose to order or not order the test as a 

routine and efficient part of the visit workflow. 

For a limited period of time after initiation of the new 

workflow, and as a way to help all involved develop the habit of 

following the new process, MAs were asked to keep a daily log 

of patients over the age of 50. The logs were meant to document 

compliance with the process and serve as an additional reminder 

to ask patients about screening (see table 2). Completed logs 

were submitted weekly from February through May 2005. We 

published cumulative results of these logs in a newsletter sent to 

the MA–physician teams. We presented small rewards to teams 

of MAs and physicians with the highest CRC screening rates. 

Data analysis 

Colonoscopy referral rates were calculated using data from the 

UUCC Epic clinical data warehouse. Referral rates were 

calculated for each month, beginning 1 January 2003, through 

31 October 2006. Patients were included in the study population 

for a given month if: (1) they had an encounter with a primary 

care physician in one of the seven clinics as identified by current 

procedural terminology (CPT) code, and (2) they were age 

50 years or older at the time of the encounter. Patients were 

excluded if they had a documented history of colectomy or 

comorbidities that contraindicated colonoscopy. 

Patients were classified as up to date on referral for 

colonoscopy if they had: (1) evidence of a colonoscopy 

356 Qual Saf Health Care 2009;18:355–359. doi:10.1136/qshc.2008.027649



Table 1 

Medical assistant screening script 

I notice that you may be due for colon cancer screening. Have you had a colonoscopy? 

‘‘Yes’’ 

Let me see if I have a copy of that report 

If you have a copy of that report, update health maintenance tab or make a note of date on progress note 

If you do not have a copy, ask when/where it was done and give patient a record release to send for report 

‘‘No’’ 

The American Cancer Society recommends colon cancer screening for everyone over age 50. Have you thought about having a 

colonoscopy? 

Enter preliminary order for physician review and decision or give patient information, depending on their response 

If patient has had a flexible sigmoidoscopy or completed stool cards, make a note 

completed within 10 years prior to the indexed encounter, (2) 

evidence in the health maintenance section of their Epic record 

of refusal of colonoscopy within a 12-month period preceding 

the encounter date or (3) evidence of referral for colonoscopy in 

the 6-month period preceding the encounter date. The remaining 

patients were considered not to be current for CRC 

screening and therefore eligible for a CRC screening referral. 

We used an X moving Range (XmR) chart to follow 

colonoscopy referral rates over time, and interrupted time series 

methods to determine if the intervention impacted those rates. 25 

For the baseline period of January 2003 through September 

2004, the mean monthly referral rate and its upper and lower 

control limits were calculated from the median absolute value of 

the range of differences between successive monthly values, 

scaled by a factor of 3.27. The control limits define the 

boundaries of random, month-to-month variation in referral 

rates in the absence of external influences or other special 

causes. The baseline control limits and mean monthly referral 

rate are projected through the postintervention period of 

October 2004 through September 2005. To determine if 

postintervention referral rates are consistently elevated above 

the baseline we used a simple run test, with the baseline mean 

as the threshold, to test for non-randomness in the postintervention 

referral rates. 26 

RESULTS 

During the study period, 23 651 patients 50 years of age or older 

were seen by primary care physicians in the UUCCs. Of these, 

169 were identified as having had colectomies or comorbidities 

that precluded colonoscopy. The remaining 23 482 patients 

generated a total of 152 271 encounters. There were 77 849 

encounters, representing 18 702 unique patients, where the 

patient was determined to be eligible for CRC screening. The 

mean number of such encounters per month was 1692 (range: 

1235 to 2232). 

Figure 1 shows the rate of colonoscopy referrals by month. 

Baseline rates for colonoscopy referrals for unscreened patients 

in the UUCCs were stable, with a mean monthly referral rate of 

6.0% (range: 4.9 to 7.4%). For the postintervention period, the 

mean rate was 11.1% (range: 5.6 to 15.9%); an absolute 

improvement of 5.1% and a relative improvement of 85%. 

Three major interventions are shown in fig 1 to illustrate the 

temporal relationship between the interventions and the 

Table 2 Manual colon cancer screening log 

Review activity 

colonoscopy referral rates. First, an upgrade to the EMR that 

changed the display of the CRC screening reminder was 

installed beginning 12 October 2004. This upgrade appeared to 

have no immediate effect on CRC screening referral rates. 

Second, physician education was completed in December 2004. 

This was followed the next month by an increase in referral 

rates to 7.5%. Third, in February 2005, MAs were educated 

about CRC screening, instructed to initiate discussions of CRC 

screening (see table 1), and use the logs to report the discussions 

(see table 2). This third intervention was followed by a large and 

sustained increase in colonoscopy referral rates. Following this 

intervention, the mean monthly referral rate increased to 13.4%, 

a relative improvement of 123%, and all values exceeded the 

baseline upper control limit of 7.3%. The probability of 

observing such a run of points by random chance is extremely 

small (p,0.01). 

DISCUSSION 

This study demonstrated a statistically significant and clinically 

meaningful increase in rates of referral for screening colonoscopy 

in a group of primary care practices. Improvement did not 

appear to be temporally related to changes in the computerised 

reminder system. A modest referral rate increase was seen 

shortly after physician education, but a large increase was seen 

after instituting an expanded role for MAs using the reminder as 

a prompt to review CRC screening status with patients and 

encourage referral for colonoscopy. We believe this system, 

especially the enhanced MA role, was responsible for increased 

rates of colonoscopies ordered in accord with recommended 

CRC screening guidelines. 

Primary care visits have multiple competing priorities including 

acute care, chronic disease management, attention to 

psychosocial needs and prevention. The latter includes multisystem 

cancer and metabolic screenings, patient education and 

immunisations. Many patients have multiple comorbidities that 

limit attention to preventive interventions such as CRC 

screening. 27 Even during visits scheduled specifically for preventive 

care, providers frequently address multiple problems. In 

addition, although prevalence of neoplasia increases with age, 

screening colonoscopy in very elderly persons (age.80 years) 

results in only 15% of the expected gain in life expectancy in 

younger patients. 28 Guideline-based recommendations may need 

adjustment for individual patient circumstances. 

Order activity 

No pop-up 

(no screening 

needed) 

Had colonoscopy 

(records in EpicCareß, 

but need to update 

Health Maintenance 

section of the record) 

Had 

colonoscopy 

(no records in 

EpicCareß) 

Sent 

release 

Due for 

colonoscopy 

(patient 

refused) 

No documentation 

(forgot to ask) 

Ordered 

colonoscopy 

Ordered flexible 

sigmoidoscopy 

Ordered 

faecal 

occult 

blood test 

Other 




Figure 1 

Colonoscopy referrals for patients not current at encounter. EMR, electronic medical record; MA, medical assistant. 

The advent of EMRs offers a unique opportunity to improve 

preventive healthcare. However, the ability of computerised 

reminders to affect physician behaviour is limited. 29 This study 

reaffirms that electronic prompts alone do not markedly 

improve rates of referral for CRC screening. It also confirms 

that provider education, a much-used method for improving 

clinical outcomes, has, at best, a limited effect on referral rates. 

This study is consistent with Bodenheimer’s observation that 

MAs ‘‘often play the key role of managing the flow of activity in 

primary care’’ and can ‘‘become the engine of improvement in 

primary care.’’ 19 MAs and other non-physician office staff 

reliably facilitate preventive and chronic care. 30–32 MA phone 

calls to patients proved a reliable and cost-effective way to 

encourage mammography adherence. 33 O’Brien et al found that 

clinical support staff are effective in routinely asking patients 

with diabetes to remove their shoes before seeing the provider as 

a way to increase the likelihood the physician will complete a 

foot examination (although these authors attributed the 

increase in foot exams to physician education more than to 

change in support staff roles). 31 A clinical trial funded by the 

Robert Wood Johnson Foundation is under way to determine 

whether a screening and intervention programme carried out by 

MAs in primary care practices can help patients improve health 

behaviours. 34 

Our results are also consistent with the findings of Kirkman et 

al, regarding common elements of successful clinical quality 

improvement (QI) interventions in outpatient practices. These 

elements include four factors: (1) the QI efforts ‘‘occur in 

‘closed’ systems with standard processes for scheduling, 

recordkeeping, and carrying out orders;’’ (2) ‘‘… physicians are 

influenced by mandates or incentive for improvement;’’ (3) 

routine aspects of care are removed from the physician, making 

nurses or others (e.g., MAs) responsible for these behaviours; (4) 

information systems are used to track data, identify high-risk 

patients, provide screening prompts, generate orders and track 

results. 30 Workflow redesign helps overcome the barriers to 

consistently translating knowledge and intent into practice. 16 In 

accord with others, we found that medical assistants armed 

with an electronic reminder more consistently facilitated orders 

about CRC screening than did physicians acting independently. 

31 32 

Limitations 

Our results may have underestimated the true rate of 

colonoscopy referral or, more broadly, CRC screening. This is 

because we only queried specific fields in our EMR for presence 

of colonoscopy results. We did not review free text progress 

notes, and we did not assess performance of other acceptable 

forms of CRC screening. Such documentation would be 

necessary to more accurately assess MA and physician response 

to the interventions and to identify the true rate of completed 

screening. 

Thus, this study may not provide an accurate estimate of 

‘‘true’’ CRC screening rates in our population. However, our 

focus in this study was on change in rates of colonoscopy 

referral for CRC screening, and we believe the methodology was 

equally accurate before and after our intervention, thus a valid 

indicator of relative change in referral rates. 

Providers tend to overestimate the number of patients they 

recommend for CRC screening. 10 Nonetheless, the acknowledged 

limitations of these data sources contributed to some 

provider skepticism about the data and may have reduced their 

motivation to participate in this project. 

Because the three phases of our intervention (provider 

education, alteration of EMR reminder and clinical workflow 

redesign) occurred in rapid sequence, it is impossible to isolate 

the effects of any one phase. While we identified the greatest 

increase in CRC screening rates after the third phase, clinical 

workflow redesign, attributing the increase exclusively to the 

expanded MA role could underestimate delayed or interacting 

effects of provider education and EMR reminder alterations. 

Our research team is unusual in its ability to implement 

change like this because we are a university-owned and operated 

practice group. This contrasts with most PBRNs, which rely on 

more arm’s-length relationships. The unified management and 

EMR implementation across all practices in this project may 

have increased compliance compared with studies in other 

settings. 

CONCLUSION 

Electronic decision support tools alone do not increase CRC 

screening referral rates. Facilitators, IT support staff and system 

changes were all necessary to effect change. The greatest barrier 

to CRC screening for providers seemed to be competing 

demands during a short patient visit. Adding redesigned clinical 

workflow, particularly an expanded role for the MA, appeared 

to increase referrals for CRC screening. These results are 

consistent with the literature on prevention and chronic 

13 30–32 

care, suggesting that this approach may be useful to 

enhance other disease-prevention and health-promotion 

358 Qual Saf Health Care 2009;18:355–359. doi:10.1136/qshc.2008.027649



interventions. Further work will be necessary to assess the 

relative impacts of individual components of such multifactorial 

system changes. 

Acknowledgements: The authors acknowledge R Lloyd and D Palmer, University of 

Utah Community Clinics, for their expertise in clinical practice redesign that included an 

expanded role for medical assistants. The authors thank J Nunu, for editorial 

assistance. 

Funding: This research was supported, in part, by grant number 1 R21 CA107216- 

01A1 from the National Cancer Institute. 

Competing interests: None. 

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