TABLE 1.

Cognitive Support Requirements

Cognitive Support Requirement		Description
1.	Determine whether the patient is in screening or surveillance mode.	For experienced primary care providers, this is an important sensemaking frame. Screening versus surveillance mode has important implications for what information the provider will access prior to the patient discussion as well as how the provider will present and discuss testing options with the patient. For those in surveillance mode, it is important to review prior findings and to ensure that the patient understands that prior findings could increase the patient’s risk for CRC. Thus, the importance of further testing at recommended intervals is greater. For those in screening mode, no additional information gathering is generally needed, and the conversation may be simpler.
2.	Obtain a big-picture perspective of the patient’s testing history.	Prior CRC test data may be found in progress notes, lab reports, GI reports, and pathology reports. During a patient encounter, it is difficult to use the EHR to access each of the required screens, locate the relevant information, and mentally integrate the data in a timely manner while talking to the patient. In fact, in some cases, finding and integrating relevant data is enough of a barrier that physicians rely on patient memory of past CRC tests and findings rather than search the EHR. This represents a considerable barrier to effective sensemaking.
3.	Know where the patient is in the screening cycle.	In most cases, the primary care provider orders a test and receives a report from the specialty clinic or lab in a few weeks. In some cases, however, the primary care provider does not receive a report. In these cases, it is difficult to determine where the process fell apart. There is generally no visibility into what happens after the test is ordered and why a test did not occur, greatly hindering the provider’s ability to detect problems with the process.
4.	Consider conditions or medications that have implications for CRC testing.	Quickly reviewing relevant conditions and medications helps the primary care provider recognize nonroutine situations and make patient-based recommendations for testing. For example, some primary care providers reported that they consider whether the patient has a condition that may increase the risk associated with the anesthesia often used with colonoscopy. For those patients, they may recommend another test modality.
5.	Assess and monitor a patient’s individual risk level for CRC.	Information related to risk stratification might be found in multiple places in the EHR, including prior progress notes and GI reports. Furthermore, risk stratification may change based on test findings or even changes in family history (e.g., a first-degree relative recently diagnosed with CRC). Primary care providers indicated that it would be useful to have the most recent data relevant to risk level available so they can quickly assess and ask relevant questions to determine whether there is a need to update their understanding of the patient’s CRC risk.
6.	Educate and inform patients.	Primary care providers report that they want each patient to understand what colon cancer is and what the screening options are. Most report that they emphasize colonoscopy as a gold standard of care because it provides a more complete view of the colon and because the gastroenterologist is able to remove precancerous polyps during the procedure. Primary care providers report common CRC misconceptions from patients include underestimation of the risk of CRC, overestimation of the risk of colonoscopy procedure, fear that the colonoscopy procedure will be uncomfortable, and belief that CRC screening is expensive. Note that these concerns reported by physicians in CTA interviews align with issues and concerns derived from surveys of patients (Beydoun & Beydoun, 2008; Vernon, 1997).

Note. CRC = colorectal cancer; CTA = cognitive task analysis; EHR = electronic health record; GI = gastroenterology.