September 29, 2025
Community health centers, or CHCs, are the only source of primary care for at least 32 million patients in the United States—a number that continues to grow. But as demand for services outpaces available staffing and resources, care teams face growing pressure to do more with less. This imbalance can affect the delivery of preventive services like cancer screenings, which remain significantly below national rates in CHC settings.
As of 2023, 73% of eligible people in the U.S. were current on colorectal cancer screening and 76% on cervical cancer screening, compared with just 44% and 52%, respectively, among CHC patients. One contributing factor is the limited time, staffing, and resources available during patient visits, when care teams must manually identify and order needed screenings.
Clinical decision support tools embedded in electronic health records offer promising solutions by streamlining these steps, but they are often underused. To improve cancer screening efforts in CHCs, it is essential to optimize how these tools are implemented and integrated into routine workflows. Making it easier for care teams to act on screening needs during routine visits can enhance early cancer detection and improve outcomes in rural and low-resourced communities.
A research study led by OCHIN, published in April 2025, found that informatics-supported clinic workflows were associated with increased rates of certain cancer screening orders. Using a rapid-cycle research approach, the study evaluated the implementation and impact of one such workflow on colorectal and cervical cancer screening orders and identified actionable opportunities to improve adoption.
Study background
Health Maintenance is a suite of tools in the OCHIN Epic EHR designed to help care teams quickly identify and place orders for preventive care. Its contents reflect clinical guidelines from the U.S. Preventive Services Task Force, the Centers for Disease Control and Prevention, and other relevant sources, such as the American Society of Colposcopy and Cervical Pathology’s cervical cancer screening tracking guidelines.
To enhance these functions and support clinical excellence for members, OCHIN developed the Care Gaps Smartset. This tool enables users to place necessary orders directly within the same EHR interface, eliminating the need for clinicians to navigate to other sections and enter them individually.
Key findings
The OCHIN-led study found that clinics and providers who used the Care Gaps Smartset had higher colorectal cancer screening order rates. Increased usage was also associated with higher order rates. However, no significant association was found between Care Gaps Smartset use and cervical cancer screening order rates, likely due to the more complex workflows involved in cervical cancer screening.
Several factors supported Care Gaps Smartset adoption:
- Clinic leaders endorsed its use as standard practice.
- Role-specific training was provided.
- Workflows were established in which rooming staff use the Care Gaps Smartset to prepare orders, allowing clinicians to simply sign and submit them.
Barriers to use included:
- Low awareness of the tool
- Functions that were not locally optimized
- Lack of training support
The figure below summarizes barriers, facilitators, and opportunities for improvement across each workflow activity involved in using the Care Gaps Smartset for cancer screening orders.
Care Gaps Smartset implementation
CGS = Care Gaps Smartset; CVC = cervical cancer
How health centers can use these results
The study identified several strategies for improving cancer screening order rates using the Care Gaps Smartset. Health centers may consider the following steps:
- Secure leadership support.
- OCHIN can help centers identify leadership champions and pilot workflows with a small team to refine implementation and highlight measurable outcomes (e.g., increased colorectal cancer screenings).
- Provide formal and ongoing training.
- OCHIN can also help develop role-specific, interactive training to support clinicians, medical assistants, and rooming staff in effectively using tools like the Care Gaps Smartset. This includes hands-on practice, structured worksheets to map workflows, and support for drop-in office hours and ad-hoc training sessions to troubleshoot workflow issues.
- Configure the Care Gaps Smartset to meet local needs.
- Connect with OCHIN and collaborate with your health center’s IT or EHR specialists to tailor the Care Gaps Smartset to your organization’s needs. Then, pilot the configured Care Gaps Smartset with a small team to ensure functionality, use data to monitor screening order rates, and gather staff feedback to guide adjustments.
- Integrate Care Gaps Smartset use into pre-visit workflows.
- Work with OCHIN to create step-by-step instructions for rooming or pre-charting staff to complete orders using the Care Gaps Smartset. Ensure the appropriate staff are involved in cervical cancer screening workflows, as non-clinical team members typically do not initiate or prepare these orders for provider review. Also, establish reliable communication methods between providers and staff to review and update pending orders during patient visits.
OCHIN is proud to advance health care research and promote clinical excellence among CHCs nationally, so everyone can enjoy access to high-quality care. To learn more about how to participate in clinical research with OCHIN, visit ochin.org.
This work was supported by the National Cancer Institute (NCI) of the National Institutes of Health (grant number: P50CA244289). This P50 program was launched by NCI as part of the Cancer Moonshot. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
