Driven by the state’s high rates of lung cancer incidence and mortality, and encouraged by the results of the landmark National Lung Screening Trial (NLST), a pulmonologist and a radiologist at St. Elizabeth Healthcare in Kentucky came together to develop their lung cancer screening strategy. They attracted the attention and buy-in of the organization’s executive leadership and secured appropriate resource allocations for the program in late 2013.

Gaining initial support helped get them off the ground, but St. Elizabeth’s team realized that staffing a dedicated team and building a broad base of support from physicians in their system was necessary for meaningful growth.

Team approach fundamental to program’s success

St. Elizabeth hired a dedicated thoracic surgeon who drove the program’s design forward and led physician outreach. St Elizabeth identified a primary care physician champion and several groups of key providers and associates, including radiologists, pulmonologists, oncologists, data analysts and report writers, process improvement specialists, value-based performance and clinical transformation leaders, and nurse navigators, who collaborated to support the program.

Coordination across this broad, interdisciplinary team was necessary to facilitate program design and operations, increase appropriate referrals, encourage proper documentation, and provide high-quality care to patients.

Outreach and education foster broad support and engagement

St. Elizabeth’s primary care physician champion worked with the lung screening program’s established foundation—pulmonology, radiology, and thoracic surgery, as well as their nurse navigators—to reach the more than 150 St. Elizabeth primary care physicians, educate them about the program, and encourage them to proactively refer eligible patients.

A key component was educating referring physicians and staff about proper documentation to ensure that the screenings were billable and incidental findings were tagged correctly, and to communicate next steps to manage patient care after screening. Getting each player on-board with the initiative was as important as building the infrastructure of the program itself.

Two techniques proved particularly helpful in motivating physicians to make appropriate referrals to the screening program. First, St. Elizabeth regularly shared the lung screening program’s achievements, including patient outcomes and testimonials, and data showing the progress of stage migration in their screened population. Second, the physician champion injected a bit of competition among the referring physicians. He tracked the referrals and on a monthly basis published the rankings of the more than 600 employed physicians in the system who made the most referrals.

St. Elizabeth carved out dedicated staff FTEs and clearly defined their responsibilities within the lung cancer screening program to support patient intake and coordination.

Medical Director of Lung Cancer Screening

St. Elizabeth named an official Medical Director of Lung Cancer Screening to oversee the program and sustain its growth and development. Officially recognizing the position and carving out time for it between his other responsibilities allowed him to effectively lead the program and foster its development.

Physicians participate in Lung Nodule Review Board and Clinic

The dedicated thoracic surgeon was committed to developing the program by garnering buy-in from groups across the organization and focusing on quality patient care. He established the Lung Nodule Review Board, which employs a rigorous and programmatic approach to maximizing benefit to St. Elizabeth patients while avoiding unnecessary and potentially harmful downstream procedures.

St. Elizabeth identified a team of physicians to dedicate a portion of their time to the screening program for both a multidisciplinary lung nodule review board and lung cancer clinic. A multidisciplinary team of radiologists, thoracic surgeons, pulmonologists, and primary care physicians run the weekly Lung Nodule Review Board. The board reviews suspicious screening scans from the prior week, as well as incidental and symptomatic scans, and develop a plan for managing each case. Whether the group recommends a surgical procedure or more follow-up scans, their goal is to judiciously reduce harm for patients and identify the most appropriate intervention.

On Thursday afternoons, a thoracic surgeon, pulmonologist, and oncologist hold a multidisciplinary lung cancer clinic. Each week they see between 2-5 patients whose cases were evaluated in the Lung Nodule Review Board. They schedule patients to see the thoracic surgeon, pulmonologist, or oncologist, individually or collectively, depending on the particular case.

Nurse navigators coordinate follow-up and communication

For several years, one full-time nurse navigator staffed the program. In 2019, St. Elizabeth added an additional full-time nurse navigator to support the significant growth in screening volumes.

When a LDCT lung cancer screening is ordered, the EHR automatically flags the order. The central scheduling team or nurse navigator identify ordered LDCT lung cancer screens and reach out to the patient to schedule imaging. The Care Management Team, a department within the broader St. Elizabeth system, ensures that the patients follow through with scheduling their LDCT screening.

Following a patient’s lung screening, their radiologist classifies the CT scan findings as category 1-4, based the Lung-RADS criteria, and sends the results to the nurse navigator. The navigator triages patient follow-up based on category:

In addition to carrying out the program’s core processes, St. Elizabeth’s nurse navigators play a major role in outreach through community events and educating primary care physicians and their staff.

St. Elizabeth’s Informatics Team and EHR Committee were highly engaged in integrating the lung screening processes in the EHR. The teams collaborated to design and implement Best Practice Alerts (BPAs) and Health Maintenance prompts to alert the physicians and staff when a patient met the eligibility criteria for lung cancer screening. These EHR alerts significantly enhance utilization of the testing.

Additionally, the team built out Epic templates and smart phrases, such as .lungscreening, and emphasized proper documentation in the EHR. These smart phrases embedded in physician notes and radiology reports allow the screening nurse navigator to identify patients who are eligible for LDCT screening, as well as patients with incidental lung nodule findings. Educating physicians and radiologists on the correct templates and smart phrases to use was crucial to enable nurse navigators to find the patient when they run a report in the EHR.

In addition to streamlining the identification process, thorough documentation is critical for billing and coding. Justifying the patient’s eligibility for LDCT lung screening to payers relies on the proper documentation. Additionally, having all elements of the required documentation allows the referring physician to bill and be compensated 0.52 wRVU for counseling the patient on lung cancer screening and engaging in shared decision making.

Relevant coding information:

G0296 — Counseling visit to discuss need for lung cancer screening using LDCT (service is for eligibility determination and shared decision making)

G0297 — LDCT for lung cancer screening

Medicare will deny G0296 and G0297 for claims that do not contain specific ICD-10 codes, for example:

Z87.891 for former smokers (personal history of nicotine dependence)

F17.21 for current smokers (nicotine dependence)

St. Elizabeth continues to assess new opportunities for improved clinician EHR education. For example, they realized that in Epic EHR, the patient’s smoking history—a key eligibility criterion—does not update automatically from year to year (i.e., if a patient’s smoking history was entered one year ago, the system will not automatically add a year to their total smoking history). As a safeguard, the provider will not be able to place an order for the lung cancer screen without ensuring the smoking history and age criteria are met and properly documented in the EHR. Thorough education and checkpoints built into the EHR can help to improve documentation of smoking history.

In an effort to further promote early lung cancer detection, St. Elizabeth built a retail screening program to reach patients at significant risk of developing lung cancer who may fall outside of payers’ screening criteria. The retail screening program provides an option to pay a flat rate of $99 for the screening.

Providers identify patients at risk of developing lung cancer by using the NCCN risk scale. This model divides risk level into low, moderate, and high risk levels. The high risk determination is further broken down into Groups 1 and 2, both of which meet NCCN criteria for annual lung cancer screening. Group 1 is defined by CMS criteria. To determine qualification for Group 2, providers utilize the Tammemagi lung cancer risk prediction model and choose an entry qualification of > 1.3% 6-year probability of contracting lung cancer. Though annual screening is recommended for patients falling within both Group 1 and 2 of the high risk category, payers do not always cover screening for Group 2 patients.

Patients can access the program through a physician referral or St. Elizabeth’s website. The website directs patients to take a quiz to preliminarily determine their eligibility for LDCT and instructs them to call their PCP or the lung screening nurse navigator directly. Appointments are then arranged for the required face-to-face encounter.

Program leadership anticipates a modest increase in volumes through the retail program, and hope to reach more patients who are eligible for screening through their patient-friendly marketing and intake tool on their website.